MEDICARE: FIRST DOOR, 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	320700000X	Physical Disabilities Residential Treatment Facility	AS630369663	MI
2	261QR0400X	Rehabilitation Clinic/Center
3	320800000X	Mental Illness Community Based Residential Treatment Facility	AS630369663	MI
4	385H00000X	Respite Care	AS630369663	MI
5	261QR0401X	Comprehensive Outpatient Rehabilitation Facility (CORF)
6	311ZA0620X	Adult Care Home Facility	AS630369663	MI
7	314000000X	Skilled Nursing Facility
8	311Z00000X	Custodial Care Facility	AS630369663	MI

General Provider Information

NPI Number	:	1750832564
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FIRST DOOR, LLC

Provider Business Mailing Address
First Line	:	25584 W 10 MILE RD
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-4826
Country	:	US
Telephone Number	:	248-877-8401
Fax Number	:	313-454-3102

Provider Business Practice Location Address
First Line	:	25584 W 10 MILE RD
Second Line	:
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-4826
Country	:	US
Telephone Number	:	248-877-8401
Fax Number	:	313-454-3102

Authorized Official
Title or Position	:	OWNER/CEO/PRESIDENT
Name	:	MR. MODEIRA JOHNSON SR.
Credential	:
Telephone Number	:	248-877-8401

Provider Enumeration Date	:	10/17/2016
Last Update Date	:	11/13/2018

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Directions to “FIRST DOOR, LLC ” Practice Location

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