Healthcare Provider Details

I. General information

NPI: 1124833900
Provider Name (Legal Business Name): VITAL SOURCE HOME CARE PROVIDERS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2025
Last Update Date: 02/18/2025
Certification Date: 02/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18945 FIELDING ST
DETROIT MI
48219-2511
US

IV. Provider business mailing address

1401 W FORT ST UNIT 441846
DETROIT MI
48244-3575
US

V. Phone/Fax

Practice location:
  • Phone: 313-492-9437
  • Fax:
Mailing address:
  • Phone: 313-492-9437
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YP1600X
TaxonomyPastoral Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name: DAMITA COLLETTE JOHNSON
Title or Position: MANAGER
Credential:
Phone: 313-492-9437