Healthcare Provider Details

I. General information

NPI: 1598989717
Provider Name (Legal Business Name): DERRICK'S ADULT FOSTER CARE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/11/2007
Last Update Date: 01/12/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4885 IVANHOE ST
DETROIT MI
48204-3675
US

IV. Provider business mailing address

PO BOX 252982
W BLOOMFIELD MI
48325-2982
US

V. Phone/Fax

Practice location:
  • Phone: 313-915-2644
  • Fax: 248-661-5024
Mailing address:
  • Phone: 248-640-4813
  • Fax: 248-661-5024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAS820281817
License Number StateMI

VIII. Authorized Official

Name: CASSANDRA L DERRICK
Title or Position: PRESIDENT, CEO
Credential: BSHCM
Phone: 248-640-4813