Healthcare Provider Details

I. General information

NPI: 1720874423
Provider Name (Legal Business Name): RANDYS PLACE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2025
Last Update Date: 05/12/2025
Certification Date: 04/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5910 LAKEWOOD ST
DETROIT MI
48213-3639
US

IV. Provider business mailing address

5816 NEWPORT ST
DETROIT MI
48213-3641
US

V. Phone/Fax

Practice location:
  • Phone: 313-479-6199
  • Fax: 313-391-5799
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310500000X
TaxonomyMental Illness Intermediate Care Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License Number
License Number State

VIII. Authorized Official

Name: ENDIA HAWKINS
Title or Position: OWNER
Credential: BSN, RN
Phone: 313-479-6199