=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336674415
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EDUCATING U4 LIFE CDC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/26/2017
-----------------------------------------------------
Last Update Date | 07/25/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19321 W CHICAGO ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48228-1739
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-267-3491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22503 GRAND RIVER AVE SUITE 19653
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48219-5034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 877-267-3491
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | MR. ALBERT EUGENE MACK
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 877-267-3491
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 252Y00000X
-----------------------------------------------------
Taxonomy Name | Early Intervention Provider Agency
-----------------------------------------------------
License Number | 6801046708
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251S00000X
-----------------------------------------------------
Taxonomy Name | Community/Behavioral Health Agency
-----------------------------------------------------
License Number | 6801011686
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------