=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326672577
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UNTIED HEARTS GROUP
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/26/2020
-----------------------------------------------------
Last Update Date | 02/27/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 45487 PENTWATER DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-244-3697
-----------------------------------------------------
Fax | 586-329-1117
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 45487 PENTWATER DR
-----------------------------------------------------
City | MACOMB
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48044-4236
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-745-1333
-----------------------------------------------------
Fax | 586-329-1117
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ABOUBACRY BA
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 586-745-1333
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------