=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679396733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KEKELIS AFC INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/06/2024
-----------------------------------------------------
Last Update Date | 11/06/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 731 LOUISA ST
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48911-5144
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-980-1925
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 26243
-----------------------------------------------------
City | LANSING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48909-6243
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | ANNA MASAMBAJI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-980-1925
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 315P00000X
-----------------------------------------------------
Taxonomy Name | Intellectual Disabilities Intermediate Care Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------