Healthcare Provider Details

I. General information

NPI: 1750954624
Provider Name (Legal Business Name): ALICE STREET HOME CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/20/2021
Last Update Date: 07/20/2021
Certification Date: 07/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29229 COTTON RD APT 104
CHESTERFIELD MI
48047-5113
US

IV. Provider business mailing address

29229 COTTON RD APT 104
CHESTERFIELD MI
48047-5113
US

V. Phone/Fax

Practice location:
  • Phone: 989-345-5458
  • Fax:
Mailing address:
  • Phone: 989-345-5458
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. JENNIFER R NELSON
Title or Position: SOLE MEMBER
Credential:
Phone: 989-345-5458