=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467948786
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | I CARE HOME SERVICES
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/10/2018
-----------------------------------------------------
Last Update Date | 07/10/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16610 WORMER ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48219-3679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-686-4280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1104
-----------------------------------------------------
City | DEARBORN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48121-1104
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-686-4280
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MS. EBONI MONIQUE HARRIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-686-4280
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number | AS820386526
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------