Healthcare Provider Details

I. General information

NPI: 1790242006
Provider Name (Legal Business Name): CIRCLE OF SUPPORT LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/22/2019
Last Update Date: 02/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29858 HANOVER BLVD
WESTLAND MI
48186-5178
US

IV. Provider business mailing address

29858 HANOVER BLVD
WESTLAND MI
48186-5178
US

V. Phone/Fax

Practice location:
  • Phone: 404-434-0070
  • Fax: 734-331-2364
Mailing address:
  • Phone: 404-434-0070
  • Fax: 734-331-2364

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State

VIII. Authorized Official

Name: KENA GEE
Title or Position: ADMINISTRATOR
Credential:
Phone: 404-434-0070