Healthcare Provider Details

I. General information

NPI: 1164878294
Provider Name (Legal Business Name): BORN FOR ME LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/07/2016
Last Update Date: 05/07/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19323 STANSBURY ST
DETROIT MI
48235-1733
US

IV. Provider business mailing address

PO BOX 14513
DETROIT MI
48214-0513
US

V. Phone/Fax

Practice location:
  • Phone: 313-215-6395
  • Fax:
Mailing address:
  • Phone: 313-215-6395
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number6801085319
License Number StateMI

VIII. Authorized Official

Name: MRS. EBONY HARVEY-JACKSON
Title or Position: CEO
Credential: LMSW
Phone: 313-215-6395