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General NPI Number Information
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NPI Number | 1124833900
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Entity Type | Organization
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Legal Business Name | VITAL SOURCE HOME CARE PROVIDERS LLC
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Dates
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Enumeration Date | 02/10/2025
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Last Update Date | 02/18/2025
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Provider Practice Location Address
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Address Line | 18945 FIELDING ST
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City | DETROIT
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State | MI
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Zip | 48219-2511
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Country | US
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Telephone | 313-492-9437
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Fax |
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Provider Business Mailing Address
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Address Line | 1401 W FORT ST UNIT 441846
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City | DETROIT
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State | MI
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Zip | 48244-3575
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Country | US
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Telephone | 313-492-9437
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Fax |
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Authorized Official
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Title or Position | MANAGER
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Name | DAMITA COLLETTE JOHNSON
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Credential |
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Telephone | 313-492-9437
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 101YP1600X
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Taxonomy Name | Pastoral Counselor
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 253Z00000X
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Taxonomy Name | In Home Supportive Care Agency
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License Number |
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License Number State |
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Taxonomy #4
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Taxonomy Code | 343900000X
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Taxonomy Name | Non-emergency Medical Transport (VAN)
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License Number |
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License Number State |
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Taxonomy #5
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Taxonomy Code | 347C00000X
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Taxonomy Name | Private Vehicle
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License Number |
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License Number State |
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Taxonomy #6
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Taxonomy Code | 374U00000X
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Taxonomy Name | Home Health Aide
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License Number |
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License Number State |
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Taxonomy #7
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number |
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License Number State |
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