Healthcare Provider Details

I. General information

NPI: 1619041183
Provider Name (Legal Business Name): LIBERAL MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/17/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

129 VIRGINIA PARK ST
DETROIT MI
48202-2000
US

IV. Provider business mailing address

14981 LIBERAL ST
DETROIT MI
48205-1905
US

V. Phone/Fax

Practice location:
  • Phone: 313-874-5404
  • Fax: 248-208-0024
Mailing address:
  • Phone: 313-526-0693
  • Fax: 248-208-0024

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number StateMI

VIII. Authorized Official

Name: MRS. KATHLEEN BLANCHE DAVIS
Title or Position: ADMINISTRATOR
Credential:
Phone: 313-874-5404