Healthcare Provider Details

I. General information

NPI: 1134203235
Provider Name (Legal Business Name): DOMUS VITA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/25/2006
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14145 FARMINGTON RD
LIVONIA MI
48154-5422
US

IV. Provider business mailing address

14145 FARMINGTON RD
LIVONIA MI
48154-5422
US

V. Phone/Fax

Practice location:
  • Phone: 734-293-0034
  • Fax: 734-293-0048
Mailing address:
  • Phone: 734-293-0034
  • Fax: 734-293-0048

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MS. PAMELA JABLONICKY
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 734-293-0034