Provider records sourced from NPPES (CMS National Plan & Provider Enumeration System). Data current as of October 4, 2026.
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NPI 1720377310

Individual provider · NPI 1720377310 Deactivated

This NPI was deactivated on September 10, 2026. The record is kept for reference and should not be used for billing or referrals.

NPI 1720377310 is listed in the national NPI registry. Works from 2 locations.

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Practice location Incomplete address

The federal record is missing the street or ZIP for this provider.

No coordinates on file. Search this address in Google Maps

Additional practice locations (1)

  • 24445 Northwestern Hwy Ste 100, Southfield, MI 48075-2436 — (248) 483-7804

Specialties & licences

Record details

NPI number1720377310
Entity typeIndividual (Type 1)
NPI enumerated—
Last updated in NPPES—