=====================================================
General NPI Number Information
=====================================================
NPI Number | 1902612906
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | BLAKELY'S TENDER CARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/05/2024
-----------------------------------------------------
Last Update Date | 12/05/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 28971 BIRCHWOOD ST
-----------------------------------------------------
City | INKSTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48141-1111
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 734-729-8223
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7076 BRIDGE WAY
-----------------------------------------------------
City | WEST BLOOMFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48322-3527
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-510-0840
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | DENISE BLAKELY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-510-0840
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 320800000X
-----------------------------------------------------
Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------