Healthcare Provider Details

I. General information

NPI: 1316244965
Provider Name (Legal Business Name): Y.A.D.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/17/2011
Last Update Date: 02/17/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18425 HICKORY ST
DETROIT MI
48205-2707
US

IV. Provider business mailing address

PO BOX 13185
DETROIT MI
48213-0185
US

V. Phone/Fax

Practice location:
  • Phone: 313-729-4547
  • Fax: 313-821-8683
Mailing address:
  • Phone: 313-729-4547
  • Fax: 313-821-8683

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0405X
TaxonomySubstance Use Disorder Rehabilitation Clinic/Center
License Number261QR0405X
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number261QA0600X
License Number StateMI

VIII. Authorized Official

Name: MRS. BLANCHE RENEE FOSTER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 313-729-4547