Healthcare Provider Details

I. General information

NPI: 1912224825
Provider Name (Legal Business Name): GABRIEL'S NEST INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2010
Last Update Date: 05/02/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20525 LAUDER ST
DETROIT MI
48235-1642
US

IV. Provider business mailing address

PO BOX 250275
WEST BLOOMFIELD MI
48325-0275
US

V. Phone/Fax

Practice location:
  • Phone: 248-789-8766
  • Fax: 805-299-4989
Mailing address:
  • Phone: 248-789-8769
  • Fax: 805-299-4989

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberAS820286839
License Number StateMI

VIII. Authorized Official

Name: MR. JERMAINE GABRIEL
Title or Position: PRESIDENT
Credential:
Phone: 248-789-8769