MEDICARE: RANDYS PLACE LLC

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	251E00000X	Home Health Agency
2	310500000X	Mental Illness Intermediate Care Facility
3	343900000X	Non-emergency Medical Transport (VAN)
4	311Z00000X	Custodial Care Facility

General Provider Information

NPI Number	:	1720874423
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RANDYS PLACE LLC

Provider Business Mailing Address
First Line	:	5816 NEWPORT ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48213-3641
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5910 LAKEWOOD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48213-3639
Country	:	US
Telephone Number	:	313-479-6199
Fax Number	:	313-391-5799

Authorized Official
Title or Position	:	OWNER
Name	:	ENDIA HAWKINS
Credential	:	BSN, RN
Telephone Number	:	313-479-6199

Provider Enumeration Date	:	04/17/2025
Last Update Date	:	05/12/2025

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Directions to “RANDYS PLACE LLC ” Practice Location

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