MEDICARE: HUDSON HOME 1 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	311ZA0620X	Adult Care Home Facility

General Provider Information

NPI Number	:	1619452588
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HUDSON HOME 1 INC

Provider Business Mailing Address
First Line	:	750 VIRGINIA PARK ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-2033
Country	:	US
Telephone Number	:	313-875-5499
Fax Number	:	313-875-5499

Provider Business Practice Location Address
First Line	:	750 VIRGINIA PARK ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48202-2033
Country	:	US
Telephone Number	:	313-875-5499
Fax Number	:	313-875-5499

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	MRS. LILLAR M HUDSON
Credential	:
Telephone Number	:	313-407-3711

Provider Enumeration Date	:	09/26/2018
Last Update Date	:	09/26/2018

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Directions to “HUDSON HOME 1 INC ” Practice Location

Language	Start Address	Practice Location

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