Healthcare Provider Details

I. General information

NPI: 1861034225
Provider Name (Legal Business Name): NORTHEND VILLAGE NON-PROFIT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 01/31/2022
Certification Date: 01/31/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8904 WOODWARD AVE
DETROIT MI
48202-1821
US

IV. Provider business mailing address

22745 CAMBRIDGE AVE
DETROIT MI
48219-1725
US

V. Phone/Fax

Practice location:
  • Phone: 313-363-7018
  • Fax: 248-608-8592
Mailing address:
  • Phone: 313-363-7018
  • Fax: 248-608-8592

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BETTY MACKIE
Title or Position: MEMBER
Credential:
Phone: 313-363-7018