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General NPI Number Information
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NPI Number | 1891917191
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Entity Type | Organization
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Legal Business Name | EXCELSIOR HOME 1 INC.
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Dates
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Enumeration Date | 05/03/2007
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Last Update Date | 08/15/2007
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Provider Practice Location Address
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Address Line | 129 VIRGINIA PARK
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City | DETROIT
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State | MI
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Zip | 48202
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Country | US
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Telephone | 313-874-5594
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Fax | 248-208-0024
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Provider Business Mailing Address
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Address Line | P.O.BOX 11387
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City | DETROIT
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State | MI
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Zip | 48202
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Country | US
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Telephone | 313-874-5404
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Fax | 248-208-0024
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | MR. KATHLEEN DAVIS
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Credential |
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Telephone | 313-874-5404
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number |
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License Number State | MI
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