Healthcare Provider Details

I. General information

NPI: 1366659906
Provider Name (Legal Business Name): ELMHURST HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 03/20/2023
Certification Date: 03/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12010 LINWOOD ST
DETROIT MI
48206-1108
US

IV. Provider business mailing address

12010 LINWOOD ST P. O. BOX 06716
DETROIT MI
48206-1108
US

V. Phone/Fax

Practice location:
  • Phone: 313-867-1002
  • Fax: 313-867-7776
Mailing address:
  • Phone: 313-867-1002
  • Fax: 313-867-7776

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number820202
License Number StateMI

VIII. Authorized Official

Name: MR. JOHN CAMPBELL ODEN
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 313-867-1002