Healthcare Provider Details

I. General information

NPI: 1619059573
Provider Name (Legal Business Name): CARSON ADULT FOSTER CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19384 JAMES COUZENS FWY
DETROIT MI
48235-1961
US

IV. Provider business mailing address

19384 JAMES COUZENS FWY
DETROIT MI
48235-1961
US

V. Phone/Fax

Practice location:
  • Phone: 313-863-7050
  • Fax: 313-863-1524
Mailing address:
  • Phone: 313-863-7050
  • Fax: 313-863-1524

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171W00000X
TaxonomyContractor
License NumberAM8220009843
License Number StateMI

VIII. Authorized Official

Name: MR. JOHNNY CARSON JR.
Title or Position: PRESIDENT
Credential:
Phone: 313-863-7050