Healthcare Provider Details

I. General information

NPI: 1306597497
Provider Name (Legal Business Name): WAKECO HOLDING COMPANY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2022
Last Update Date: 01/11/2022
Certification Date: 01/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 ECKLES RD STE 103
PLYMOUTH MI
48170-4245
US

IV. Provider business mailing address

PO BOX 51723
LIVONIA MI
48151-5723
US

V. Phone/Fax

Practice location:
  • Phone: 313-288-9736
  • Fax:
Mailing address:
  • Phone: 734-421-4010
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code291U00000X
TaxonomyClinical Medical Laboratory
License Number
License Number State

VIII. Authorized Official

Name: CODY ISAIAH STEPHENS
Title or Position: PRESIDENT
Credential:
Phone: 313-288-9736