Healthcare Provider Details

I. General information

NPI: 1154174530
Provider Name (Legal Business Name): BIG FIVE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/08/2024
Certification Date: 04/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1718 ELMWOOD RD
LANSING MI
48917-1550
US

IV. Provider business mailing address

1718 ELMWOOD RD
LANSING MI
48917-1550
US

V. Phone/Fax

Practice location:
  • Phone: 702-628-6809
  • Fax:
Mailing address:
  • Phone: 702-628-6809
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: KEYONIE JAMES
Title or Position: OWNER/LICENSEE DESIGNEE
Credential:
Phone: 702-628-6809