Healthcare Provider Details

I. General information

NPI: 1912291667
Provider Name (Legal Business Name): EVOLVED SENIOR AND ADULT DAY CARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/30/2011
Last Update Date: 05/30/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15002 ASHTON RD
DETROIT MI
48223-2349
US

IV. Provider business mailing address

15002 ASHTON RD
DETROIT MI
48223-2349
US

V. Phone/Fax

Practice location:
  • Phone: 313-451-1228
  • Fax: 313-493-0925
Mailing address:
  • Phone: 313-451-1228
  • Fax: 313-493-0925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMI

VIII. Authorized Official

Name: MS. KELLY K ESTELL
Title or Position: OWNER
Credential:
Phone: 313-451-1228