=====================================================
General NPI Number Information
=====================================================
NPI Number | 1437449600
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | 5K ADULT DAY CARE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/08/2011
-----------------------------------------------------
Last Update Date | 04/08/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16352 E WARREN AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48224-2716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-854-0082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 16352 E WARREN AVE
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48224-2716
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-854-0082
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. KIRK YOUNG
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-854-0082
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------