Healthcare Provider Details

I. General information

NPI: 1659621597
Provider Name (Legal Business Name): BOYS TO MEN GROUP HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2012
Last Update Date: 09/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6025 LITCHFIELD LN
KALAMAZOO MI
49009-9128
US

IV. Provider business mailing address

6025 LITCHFIELD LN
KALAMAZOO MI
49009-9128
US

V. Phone/Fax

Practice location:
  • Phone: 269-254-8444
  • Fax:
Mailing address:
  • Phone: 269-254-8444
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code322D00000X
TaxonomyEmotionally Disturbed Childrens' Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. ANTHONY POPLAR
Title or Position: CO-OWNER
Credential:
Phone: 269-998-9343