=====================================================
General NPI Number Information
=====================================================
NPI Number | 1487317210
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MY PEACEFUL REFUGE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2021
-----------------------------------------------------
Last Update Date | 10/22/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 20428 NORBORNE
-----------------------------------------------------
City | REDFORD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48240-1109
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-492-8951
-----------------------------------------------------
Fax | 248-282-0658
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2050 SOUTH BLVD UNIT 175
-----------------------------------------------------
City | BLOOMFIELD HILLS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48303-7007
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-492-8951
-----------------------------------------------------
Fax | 248-282-0658
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR - CARE PROVIDER
-----------------------------------------------------
Name | CAROL DAVIS
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-492-8951
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251E00000X
-----------------------------------------------------
Taxonomy Name | Home Health Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------