=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215621511
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CHARLIES ABUNDANT HOME HEALTH CARE AGENCY LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2023
-----------------------------------------------------
Last Update Date | 06/21/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 WOODWARD AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48226-1904
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-261-5699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5116 E OUTER DR
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48234-3402
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-261-5699
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MRS. CHARLESZETTA CHRISTINA GULLEDGE
-----------------------------------------------------
Credential | CEO
-----------------------------------------------------
Telephone | 168-229-4500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------