MEDICARE: A SERVANTS HEART GROUP LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse

General Provider Information

NPI Number	:	1265176093
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	A SERVANTS HEART GROUP LLC

Provider Business Mailing Address
First Line	:	20130 PORTAGE TRL
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-4944
Country	:	US
Telephone Number	:	248-773-2526
Fax Number	:

Provider Business Practice Location Address
First Line	:	20130 PORTAGE TRL
Second Line	:
City	:	CLINTON TOWNSHIP
State	:	MI
Zip	:	48038-4944
Country	:	US
Telephone Number	:	248-773-2526
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	LAUREN STANFORD
Credential	:
Telephone Number	:	248-773-2526

Provider Enumeration Date	:	04/27/2022
Last Update Date	:	04/27/2022

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