MEDICARE: MOM'S HEALING HANDS, 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	253J00000X	Foster Care Agency

General Provider Information

NPI Number	:	1730658717
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOM'S HEALING HANDS, LLC

Provider Business Mailing Address
First Line	:	937 E GRAND BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-1964
Country	:	US
Telephone Number	:	313-551-1668
Fax Number	:

Provider Business Practice Location Address
First Line	:	1027 E GRAND BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-1926
Country	:	US
Telephone Number	:	313-922-4315
Fax Number	:

Authorized Official
Title or Position	:	PROVIDER/LICENSEE
Name	:	PATSY A BOLDEN
Credential	:
Telephone Number	:	313-551-1668

Provider Enumeration Date	:	11/19/2018
Last Update Date	:	11/19/2018

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