NPIMap

Organization Active NPI

Woodward Boulevard Medical Building

  • Clinic/Center
  • Detroit, MI
National Provider Identifier
1689151946
Registry record updated Nov 13, 2020
On this page

Key facts

NPPES NPI Registry
Primary specialty
Clinic/CenterTaxonomy code 261Q00000X
Legal business name
WOODWARD BOULEVARD MEDICAL BUILDING
Practice address
5830 Conner St
Detroit, MI 48213-3458
Phone
(313) 924-1456
Fax
(313) 636-2290
NPI assigned
Jul 19, 2018
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Nov 13, 2020

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Latonya Wallace-Hardiman, BA, MSANPI 1053818039
Title
Owner
Phone
(313) 715-7170

Authorized official NPPES reports the official by name only. The link goes to the one practitioner connected to this organization with that name.

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Clinic/Center 261Q00000X Primary

Addresses

Primary practice location

5830 Conner St
Detroit, MI 48213-3458

Mailing address

5830 Conner St
Detroit, MI 48213-3458
Phone (313) 458-8804

Other identifiers 1

IdentifierTypeStateIssuer
1053818039OtherMIN/A

National Provider Directory

National Provider Directory

Practitioners & affiliated clinicians

Practitioners 1

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1531958400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1605225600000",
    "number": "1689151946",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "5830 CONNER ST",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482133458",
            "telephone_number": "313-458-8804",
            "fax_number": "313-636-2290"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "5830 CONNER ST",
            "city": "DETROIT",
            "state": "MI",
            "postal_code": "482133458",
            "telephone_number": "313-924-1456",
            "fax_number": "313-636-2290"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "WOODWARD BOULEVARD MEDICAL BUILDING",
        "organizational_subpart": "NO",
        "enumeration_date": "2018-07-19",
        "last_updated": "2020-11-13",
        "certification_date": "2020-11-13",
        "status": "A",
        "authorized_official_last_name": "WALLACE-HARDIMAN",
        "authorized_official_first_name": "LATONYA",
        "authorized_official_title_or_position": "OWNER",
        "authorized_official_telephone_number": "313-715-7170",
        "authorized_official_credential": "BA, MSA"
    },
    "taxonomies": [
        {
            "code": "261Q00000X",
            "taxonomy_group": "",
            "desc": "Clinic/Center",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "N/A",
            "identifier": "1053818039",
            "state": "MI"
        }
    ],
    "endpoints": [],
    "other_names": []
}

Other providers in Detroit, MI

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Nov 13, 2020; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.