Basic Information
| Provider Information | |||||||||
| NPI: | 1932781119 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | TETARBE | ||||||||
| FirstName: | MANIK | ||||||||
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| Mailing Information | |||||||||
| Address1: | 37323 S HEATHER CT | ||||||||
| Address2: | |||||||||
| City: | WESTLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481855582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7344764630 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4201 ST ANTOINE ST. | ||||||||
| Address2: | UHC-9C | ||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482014820 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137455146 | ||||||||
| FaxNumber: | 3138660880 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/26/2021 | ||||||||
| LastUpdateDate: | 04/26/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 04/26/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.