=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558169839
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. KEITH BURELL HUDSON JR.
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/04/2025
-----------------------------------------------------
Last Update Date | 03/04/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 23344 PLUMBROOKE DR
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-7811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-675-2052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 23344 PLUMBROOKE DR
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-7811
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-675-2052
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 374U00000X
-----------------------------------------------------
Taxonomy Name | Home Health Aide
-----------------------------------------------------
License Number | H325-465-101-313
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------