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General NPI Number Information
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NPI Number | 1083041594
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Entity Type | Organization
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Legal Business Name | AB KHA #1 PLACE ADULT CARE HOME
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Dates
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Enumeration Date | 09/28/2013
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Last Update Date | 09/28/2013
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Provider Practice Location Address
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Address Line | 20815 MONTROSE AVE
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City | WARREN
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State | MI
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Zip | 48089-3464
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Country | US
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Telephone | 313-627-5885
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 5192
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City | WARREN
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State | MI
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Zip | 48090-5192
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Country | US
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Telephone | 313-627-5885
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | RODRICK BARNES
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Credential |
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Telephone | 313-627-5885
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number |
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License Number State | MI
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