Provider Demographics
NPI:1083041594
Name:AB KHA #1 PLACE ADULT CARE HOME
Entity Type:Organization
Organization Name:AB KHA #1 PLACE ADULT CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:RODRICK
Authorized Official - Middle Name:
Authorized Official - Last Name:BARNES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-627-5885
Mailing Address - Street 1:PO BOX 5192
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48090-5192
Mailing Address - Country:US
Mailing Address - Phone:313-627-5885
Mailing Address - Fax:
Practice Address - Street 1:20815 MONTROSE AVE
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48089-3464
Practice Address - Country:US
Practice Address - Phone:313-627-5885
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-28
Last Update Date:2013-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home