MEDICARE: EMMANUEL HOUSE

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	320800000X	Mental Illness Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1932823150
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EMMANUEL HOUSE

Provider Business Mailing Address
First Line	:	14750 SAINT MARYS ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-1862
Country	:	US
Telephone Number	:	131-339-7237
Fax Number	:

Provider Business Practice Location Address
First Line	:	14750 SAINT MARYS ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48227-1862
Country	:	US
Telephone Number	:	313-397-2372
Fax Number	:

Authorized Official
Title or Position	:	DIRECTOR
Name	:	TIMOTHY ARTHUR THOMPSON
Credential	:
Telephone Number	:	313-397-2372

Provider Enumeration Date	:	09/30/2022
Last Update Date	:	09/30/2022

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Directions to “EMMANUEL HOUSE ” Practice Location

Language	Start Address	Practice Location

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