Organization Name: | PETER L WICKENS D.O.,P.C. |
NPI Number: | 1003083957 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | PETER L WICKENS (PRESIDENT) |
Mailing Address: | 14050 E 14 Mile Rd Warren |
State: | MI US |
Postal Code: | 480885765 |
Phone Number: | 5862932088 |
Fax Number: | 5862935502 |
NPI Enumeration Date: | 05/09/2008 |
NPI Last Update Date: | 05/09/2008 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QP2300X |
License Number: | 5101006061 |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | MI |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Primary Care |
Taxonomy Definition: |