Healthcare Provider Details

I. General information

NPI: 1568602050
Provider Name (Legal Business Name): VISITING HOME MD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2009
Last Update Date: 02/25/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4239 ISABELLE ST
PORTAGE MI
49024-1770
US

IV. Provider business mailing address

9245 AUSTIN DR
PORTAGE MI
49002-6403
US

V. Phone/Fax

Practice location:
  • Phone: 269-350-8463
  • Fax: 269-382-4808
Mailing address:
  • Phone: 917-816-4427
  • Fax: 269-382-4808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number4301087182
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number4301087182
License Number StateMI

VIII. Authorized Official

Name: DR. JUVENAL LIPANA CASTILLO
Title or Position: MANAGING MEMBER
Credential: MD
Phone: 269-350-8463