Provider Demographics
NPI:1104398940
Name:PAYNE, RUBIE JEAN
Entity Type:Individual
Prefix:
First Name:RUBIE
Middle Name:JEAN
Last Name:PAYNE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3225 FOREST HILL AVE
Mailing Address - Street 2:
Mailing Address - City:FLINT
Mailing Address - State:MI
Mailing Address - Zip Code:48504-2653
Mailing Address - Country:US
Mailing Address - Phone:810-422-5044
Mailing Address - Fax:810-422-5044
Practice Address - Street 1:G3500 FLUSHING RD STE 209
Practice Address - Street 2:
Practice Address - City:FLINT
Practice Address - State:MI
Practice Address - Zip Code:48504-4247
Practice Address - Country:US
Practice Address - Phone:810-422-5044
Practice Address - Fax:810-422-5044
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-18
Last Update Date:2018-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251E00000X, 253Z00000X, 376J00000X, 385H00000X
MI372500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
No251E00000XAgenciesHome Health
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Multi-Specialty
No385H00000XRespite Care FacilityRespite Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI866096Medicaid