MEDICARE: LURRANAH SAFE HAVEN LLC

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	251J00000X	Nursing Care Agency
2	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1487341459
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LURRANAH SAFE HAVEN LLC

Provider Business Mailing Address
First Line	:	39449 DELLA ROSA DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-5227
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	39449 DELLA ROSA DR
Second Line	:
City	:	STERLING HEIGHTS
State	:	MI
Zip	:	48313-5227
Country	:	US
Telephone Number	:	313-870-8736
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHANTIQUE LASEAN DORTCH
Credential	:	LPN
Telephone Number	:	313-870-8736

Provider Enumeration Date	:	04/20/2023
Last Update Date	:	04/20/2023

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