1598989717 NPI number — DERRICK'S ADULT FOSTER CARE INC

Table of content: (NPI 1598989717)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598989717 NPI number — DERRICK'S ADULT FOSTER CARE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DERRICK'S ADULT FOSTER CARE INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1598989717
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 252982
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
W BLOOMFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48325-2982
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-640-4813
Provider Business Mailing Address Fax Number:
248-661-5024

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4885 IVANHOE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DETROIT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48204-3675
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-915-2644
Provider Business Practice Location Address Fax Number:
248-661-5024
Provider Enumeration Date:
04/11/2007

Additional Information

Authorized Official

Authorized Official Last Name:
DERRICK
Authorized Official First Name:
CASSANDRA
Authorized Official Middle Name:
L
Authorized Official Title or Position:
PRESIDENT, CEO
Authorized Official Telephone Number:
248-640-4813

Provider Taxonomy Codes

  • Taxonomy code: 311ZA0620X , with the licence number:  AS820281817 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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