Healthcare Provider Details

I. General information

NPI: 1609737113
Provider Name (Legal Business Name): FORTY MILE FAMILY FARMS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2025
Last Update Date: 11/24/2025
Certification Date: 11/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6491 HIVON RD
CARLETON MI
48117-9547
US

IV. Provider business mailing address

1921 KNOLLWOOD BND
YPSILANTI MI
48198-9551
US

V. Phone/Fax

Practice location:
  • Phone: 567-343-3238
  • Fax:
Mailing address:
  • Phone: 567-343-3238
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name: MR. MAJE-LLOYD HOGAN
Title or Position: BARN MANAGER
Credential:
Phone: 567-343-3238