Healthcare Provider Details

I. General information

NPI: 1891094892
Provider Name (Legal Business Name): BLUE LEAF HOMECARE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/16/2011
Last Update Date: 09/07/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18701 GRAND RIVER AVE # 327
DETROIT MI
48223-2214
US

IV. Provider business mailing address

29488 WOODWARD AVE #234
ROYAL OAK MI
48073-0903
US

V. Phone/Fax

Practice location:
  • Phone: 313-405-7668
  • Fax: 313-450-4321
Mailing address:
  • Phone: 313-405-7668
  • Fax: 313-450-4321

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License Number
License Number State

VIII. Authorized Official

Name: MS. TATISHA MILLER
Title or Position: OWNER/ CHIEF OPERATING OFFICER
Credential:
Phone: 313-405-7668