Healthcare Provider Details

I. General information

NPI: 1497058549
Provider Name (Legal Business Name): CLW ADULT DAY CARE SERVICE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2010
Last Update Date: 12/13/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10450 W JEFFERSON AVE
RIVER ROUGE MI
48218-1334
US

IV. Provider business mailing address

10450 W JEFFERSON AVE
RIVER ROUGE MI
48218-1334
US

V. Phone/Fax

Practice location:
  • Phone: 313-575-3573
  • Fax: 313-842-0066
Mailing address:
  • Phone: 313-575-3573
  • Fax: 313-842-0066

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QA0600X
TaxonomyAdult Day Care Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. NAKEYSHA CATHERINE WISDOM
Title or Position: C.E.O
Credential:
Phone: 313-575-3573