=====================================================
General NPI Number Information
=====================================================
NPI Number | 1073223723
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNIQUE HOME OF LOVE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/02/2022
-----------------------------------------------------
Last Update Date | 12/02/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 17200 E 10 MILE RD STE 270
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-3355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-324-2144
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 17200 E 10 MILE RD STE 270
-----------------------------------------------------
City | EASTPOINTE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48021-3355
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | BRYANNA JACKSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-324-2144
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251T00000X
-----------------------------------------------------
Taxonomy Name | PACE Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------