Provider Demographics
NPI:1093990384
Name:MACOMB RESIDENTIAL OPPORTUNITIES, INC.
Entity Type:Organization
Organization Name:MACOMB RESIDENTIAL OPPORTUNITIES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TED
Authorized Official - Middle Name:EDWARD
Authorized Official - Last Name:DEVANTIER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-469-4480
Mailing Address - Street 1:2 CROCKER BLVD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-2528
Mailing Address - Country:US
Mailing Address - Phone:586-469-4480
Mailing Address - Fax:586-469-4799
Practice Address - Street 1:2 CROCKER BLVD
Practice Address - Street 2:SUITE 205
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-2528
Practice Address - Country:US
Practice Address - Phone:586-469-4480
Practice Address - Fax:586-469-4799
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-01-04
Last Update Date:2008-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities