Healthcare Provider Details

I. General information

NPI: 1255665436
Provider Name (Legal Business Name): MAKA SIL & GROUP HOME, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2009
Last Update Date: 07/10/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24123 GREENFIELD RD STE 307
SOUTHFIELD MI
48075-3125
US

IV. Provider business mailing address

24123 GREENFIELD RD STE 307
SOUTHFIELD MI
48075-3125
US

V. Phone/Fax

Practice location:
  • Phone: 248-595-8108
  • Fax: 248-595-8237
Mailing address:
  • Phone: 248-595-8108
  • Fax: 248-595-8237

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. RAYMOND KYLE WILLIAMS JR.
Title or Position: ASSISTANT DIRECTOR
Credential:
Phone: 313-347-6334