=====================================================
General NPI Number Information
=====================================================
NPI Number | 1063741007
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DIVERSITY HOME CARE SERVICES LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/22/2009
-----------------------------------------------------
Last Update Date | 01/10/2012
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27208 SOUTHFIELD RD 7
-----------------------------------------------------
City | LATHRUP VILLAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-7912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-483-9220
-----------------------------------------------------
Fax | 248-483-9221
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 27208 SOUTHFIELD RD 7
-----------------------------------------------------
City | LATHRUP VILLAGE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48076-7912
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-483-9220
-----------------------------------------------------
Fax | 248-483-9221
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MR. MAREK JOZEF GAUL
-----------------------------------------------------
Credential | RPT
-----------------------------------------------------
Telephone | 248-483-9220
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------