Provider Demographics
NPI:1205205481
Name:CARE CREST
Entity Type:Organization
Organization Name:CARE CREST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTHCARE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THERICA
Authorized Official - Middle Name:
Authorized Official - Last Name:GIVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-421-9835
Mailing Address - Street 1:15365 HILL CT
Mailing Address - Street 2:
Mailing Address - City:ROSEVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48066-3119
Mailing Address - Country:US
Mailing Address - Phone:586-879-0114
Mailing Address - Fax:
Practice Address - Street 1:15365 HILL CT
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-3119
Practice Address - Country:US
Practice Address - Phone:586-879-0114
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-09-17
Last Update Date:2016-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI632127261QH0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherEIN
MI2=========Medicaid