MEDICARE: DERRICK'S ADULT FOSTER CARE 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		MI

General Provider Information

NPI Number	:	1669674917
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DERRICK'S ADULT FOSTER CARE INC

Provider Business Mailing Address
First Line	:	PO BOX 252983
Second Line	:
City	:	WEST BLOOMFIELD
State	:	MI
Zip	:	48325-2983
Country	:	US
Telephone Number	:	248-640-4813
Fax Number	:	248-661-5024

Provider Business Practice Location Address
First Line	:	5004 31ST ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48210-2537
Country	:	US
Telephone Number	:	313-897-3385
Fax Number	:	248-661-5024

Authorized Official
Title or Position	:	PRESIDENT, CEO, LICENSEE
Name	:	CASSANDRA L DERRICK
Credential	:
Telephone Number	:	248-640-4813

Provider Enumeration Date	:	05/31/2007
Last Update Date	:	08/22/2020

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