Healthcare Provider Details

I. General information

NPI: 1265576540
Provider Name (Legal Business Name): FAIRFIELD RESIDENTIAL CARE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16554 FAIRFIELD ST
DETROIT MI
48221-3005
US

IV. Provider business mailing address

17141 NEW JERSEY ST
SOUTHFIELD MI
48075-2985
US

V. Phone/Fax

Practice location:
  • Phone: 313-861-8123
  • Fax:
Mailing address:
  • Phone: 313-550-8126
  • Fax: 248-559-0974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateMI

VIII. Authorized Official

Name: MS. HEIDI L LUTER
Title or Position: ADMINISTRATOR
Credential: LPC
Phone: 313-550-8126