Healthcare Provider Details

I. General information

NPI: 1811429798
Provider Name (Legal Business Name): MIZPAH GROUP HOME INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/30/2017
Last Update Date: 03/30/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24375 LAFAYETTE CIR
SOUTHFIELD MI
48075-2560
US

IV. Provider business mailing address

24375 LAFAYETTE CIR
SOUTHFIELD MI
48075-2560
US

V. Phone/Fax

Practice location:
  • Phone: 248-796-2639
  • Fax: 248-796-2639
Mailing address:
  • Phone: 248-796-2639
  • Fax: 248-796-2639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ALONZO KEVIN MORGAN SR.
Title or Position: DIRECTOR
Credential: M.S.
Phone: 248-796-2639