=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477105369
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CAM FAM COMMUNITY CARE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/11/2019
-----------------------------------------------------
Last Update Date | 07/11/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 16718 VAUGHAN ST
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48219-3356
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-721-3480
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 22200 W 11 MILE RD UNIT 3035
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48037-7082
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-636-5924
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MRS. KIMBERLY LATRIESE CAMPBELL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-721-2558
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253Z00000X
-----------------------------------------------------
Taxonomy Name | In Home Supportive Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------