1861510679 NPI number — MR. ROGER JAMES GREGORY ICADC, ICCS

Table of content: MISS CASSANDRA STAR GONZALEZ B.S., B.A., QMHA (NPI 1124809850)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1861510679 NPI number — MR. ROGER JAMES GREGORY ICADC, ICCS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
GREGORY
Provider First Name:
ROGER
Provider Middle Name:
JAMES
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
ICADC, ICCS
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1861510679
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
06/18/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9605 WEST GRAND RIVER AVENUE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
DETROIT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48204
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
313-834-5930
Provider Business Mailing Address Fax Number:
313-834-4541

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
9605 WEST GRAND RIVER
Provider Second Line Business Practice Location Address:
NARDIN PARK RECOVERY CENTER
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48204
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-867-8015
Provider Business Practice Location Address Fax Number:
313-867-8040
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 101YA0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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