Juanita Charleston
Individual provider Active NPI Contractor · Detroit, MI
NPI 1134745995 · NPPES record last updated Jun 17, 2020
Key facts
- NPI
- 1134745995
- Entity type
- Individual (NPI type 1)
- Primary specialty
- Contractor 171W00000X
- Practice address
- 15941 Fairfield St
Detroit, MI 48238-4123 - Phone
- (313) 855-6035
- Fax
- (313) 345-4592
- NPI assigned
- Jun 17, 2020
- Sex
- Female
- Sole proprietor
- No
Organizations & group practices 1
Medicare participation
- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
- Medicare enrollment (NPD)
- No
Practice roles
| Organization | Specialty | Status | New patients |
|---|---|---|---|
| Lakeridge Village, Inc. | Current |
Accepting new patients |
Specialties & licenses
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Contractor | 171W00000X | Yes |
Addresses
Primary practice location
15941 Fairfield St
Detroit, MI 48238-4123
Mailing address
15941 Fairfield St
Detroit, MI 48238-4123
Phone (313) 345-4310
Other identifiers
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 363849916 | Medicaid | MI |
Electronic endpoints
| Type | Endpoint | Use | Affiliation |
|---|---|---|---|
| Other URL | |||
| Other URL |
Other providers in Detroit, MI
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Record last updated by the provider on Jun 17, 2020. Information in NPPES is self-reported and not verified by CMS.
- NUCC Health Care Provider Taxonomy: specialty names.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.