MEDICARE: EXECUTIVE CARE

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	164W00000X	Licensed Practical Nurse

General Provider Information

NPI Number	:	1770145872
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EXECUTIVE CARE

Provider Business Mailing Address
First Line	:	8951 RUTHERFORD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48228-2131
Country	:	US
Telephone Number	:	800-575-5290
Fax Number	:

Provider Business Practice Location Address
First Line	:	8951 RUTHERFORD ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48228-2131
Country	:	US
Telephone Number	:	800-575-5290
Fax Number	:

Authorized Official
Title or Position	:	NURSE
Name	:	TISCUR GWENDOLYN TAYLOR
Credential	:	LPN
Telephone Number	:	800-575-5270

Provider Enumeration Date	:	06/28/2019
Last Update Date	:	06/28/2019

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Directions to “EXECUTIVE CARE ” Practice Location

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