=====================================================
General NPI Number Information
=====================================================
NPI Number | 1710119375
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CARSON AFC, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/17/2009
-----------------------------------------------------
Last Update Date | 08/17/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 19384 JAMES COUZENS FWY
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48235-1961
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-863-7050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 19384 JAMES COUZENS
-----------------------------------------------------
City | DETROIT
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48235
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-863-7050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | JOHNNY CARSON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 31386370510
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number | AM820009843
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------