MEDICARE: GROWING MINDS LEARNING SERVICES, INC.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care	244956	MI

General Provider Information

NPI Number	:	1457503088
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GROWING MINDS LEARNING SERVICES, INC.

Provider Business Mailing Address
First Line	:	5852 DARB LAKE DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324-2105
Country	:	US
Telephone Number	:	248-763-5350
Fax Number	:

Provider Business Practice Location Address
First Line	:	5852 DARB LAKE DR
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48324-2105
Country	:	US
Telephone Number	:	248-763-5350
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER- EDUCATIONAL SPECIALIST
Name	:	MR. DAVID PALAGANAS FULLER
Credential	:	BS
Telephone Number	:	248-854-3699

Provider Enumeration Date	:	10/14/2008
Last Update Date	:	10/14/2008

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