Provider Demographics
NPI:1952986812
Name:INDEPENDENT CARE CENTER PLLC
Entity Type:Organization
Organization Name:INDEPENDENT CARE CENTER PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KENQUILLIA
Authorized Official - Middle Name:
Authorized Official - Last Name:NELSON-WARE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-657-4176
Mailing Address - Street 1:18161 W 13 MILE RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-1113
Mailing Address - Country:US
Mailing Address - Phone:248-480-4183
Mailing Address - Fax:248-792-2631
Practice Address - Street 1:18161 W 13 MILE RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-1113
Practice Address - Country:US
Practice Address - Phone:248-480-4183
Practice Address - Fax:248-792-2631
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-03-12
Last Update Date:2021-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center