Healthcare Provider Details

I. General information

NPI: 1609209634
Provider Name (Legal Business Name): DETROIT FAMILY HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/13/2013
Last Update Date: 12/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17180 INDIANA ST
DETROIT MI
48221-2445
US

IV. Provider business mailing address

17180 INDIANA ST
DETROIT MI
48221-2445
US

V. Phone/Fax

Practice location:
  • Phone: 313-270-7751
  • Fax: 313-270-7291
Mailing address:
  • Phone: 313-270-7751
  • Fax: 313-270-7291

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License NumberAS820338244
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAS820338244
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License NumberAS820338244
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberAS820338244
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberAS820338244
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License NumberAS820338244
License Number StateMI
# 7
Primary TaxonomyY
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberAS820338244
License Number StateMI

VIII. Authorized Official

Name: MR. JEAN FELIX NYAMBIO
Title or Position: CEO
Credential: CRNA
Phone: 301-332-3009