Healthcare Provider Details

I. General information

NPI: 1386266245
Provider Name (Legal Business Name): AH LAKESIDE I LDHA LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/14/2020
Last Update Date: 07/15/2021
Certification Date: 07/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15731 19 MILE RD
CLINTON TOWNSHIP MI
48038-6315
US

IV. Provider business mailing address

15731 19 MILE RD
CLINTON TOWNSHIP MI
48038-6315
US

V. Phone/Fax

Practice location:
  • Phone: 586-263-0081
  • Fax: 586-412-1672
Mailing address:
  • Phone: 586-263-0081
  • Fax: 586-412-1672

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332U00000X
TaxonomyHome Delivered Meals
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: AUBREY BROHL
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 586-263-0081