Healthcare Provider Details

I. General information

NPI: 1144906538
Provider Name (Legal Business Name): VINCULUM CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/22/2023
Last Update Date: 11/27/2023
Certification Date: 11/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5316 LAKESHORE RD
FORT GRATIOT MI
48059-3118
US

IV. Provider business mailing address

5316 LAKESHORE RD
FORT GRATIOT MI
48059-3118
US

V. Phone/Fax

Practice location:
  • Phone: 810-357-8792
  • Fax:
Mailing address:
  • Phone: 810-357-8792
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code163WH1000X
TaxonomyHospice Registered Nurse
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. ELIA EJAZ HUSSAIN
Title or Position: PRESIDENT
Credential:
Phone: 810-357-8792