Healthcare Provider Details

I. General information

NPI: 1780436691
Provider Name (Legal Business Name): FIVE STAR MEDICAL LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2024
Last Update Date: 04/03/2024
Certification Date: 04/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5260 IVANHOE ST
DETROIT MI
48204-3632
US

IV. Provider business mailing address

5260 IVANHOE ST
DETROIT MI
48204-3632
US

V. Phone/Fax

Practice location:
  • Phone: 313-407-2088
  • Fax:
Mailing address:
  • Phone: 313-407-2088
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MRS. KADEJAH DORENA COON
Title or Position: CEO
Credential:
Phone: 313-407-2088