Healthcare Provider Details

I. General information

NPI: 1336674415
Provider Name (Legal Business Name): EDUCATING U4 LIFE CDC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/26/2017
Last Update Date: 07/25/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19321 W CHICAGO ST
DETROIT MI
48228-1739
US

IV. Provider business mailing address

22503 GRAND RIVER AVE SUITE 19653
DETROIT MI
48219-5034
US

V. Phone/Fax

Practice location:
  • Phone: 877-267-3491
  • Fax:
Mailing address:
  • Phone: 877-267-3491
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6801011686
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number6801046708
License Number StateMI

VIII. Authorized Official

Name: MR. ALBERT EUGENE MACK
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 877-267-3491