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General NPI Number Information
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NPI Number | 1598089773
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Entity Type | Organization
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Legal Business Name | CREEKWOOD TRAIL ADULT FOSTER CARE HOME
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Dates
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Enumeration Date | 03/17/2010
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Last Update Date | 03/17/2010
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Provider Practice Location Address
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Address Line | 10078 CREEKWOOD TRAIL
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City | DAVISBURG
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State | MI
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Zip | 48350-2058
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Country | US
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Telephone | 248-625-0869
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Fax | 248-620-9403
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Provider Business Mailing Address
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Address Line | 10078 CREEKWOOD TRL 240 O'RILEY COURT
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City | DAVISBURG
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State | MI
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Zip | 48350-2058
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Country | US
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Telephone | 248-625-0869
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Fax | 248-620-9403
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Authorized Official
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Title or Position | HOME CARE PROVIDER
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Name | MS. CAROLYN ANN WILSON
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Credential |
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Telephone | 248-625-0869
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302F00000X
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Taxonomy Name | Exclusive Provider Organization
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License Number | AS630277210
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License Number State | MI
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