Healthcare Provider Details

I. General information

NPI: 1841087848
Provider Name (Legal Business Name): VITALITY ADULT FOSTER CARE HOME CO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2025
Last Update Date: 04/22/2025
Certification Date: 04/22/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11445 MINDEN ST
DETROIT MI
48205-3762
US

IV. Provider business mailing address

26026 TELEGRAPH RD STE 200
SOUTHFIELD MI
48033-2560
US

V. Phone/Fax

Practice location:
  • Phone: 248-995-5410
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State

VIII. Authorized Official

Name: BRENAE P WEAVER
Title or Position: FACILITY ADMINISTRATOR
Credential: RN
Phone: 248-995-5410