Provider Demographics
NPI:1225511157
Name:MILLER & MOSS AFC
Entity Type:Organization
Organization Name:MILLER & MOSS AFC
Other - Org Name:ROSE'S PLACE II
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:CHARISE
Authorized Official - Middle Name:
Authorized Official - Last Name:MUHAMMAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-758-8075
Mailing Address - Street 1:3409 IRENE ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-2124
Mailing Address - Country:US
Mailing Address - Phone:734-721-9630
Mailing Address - Fax:734-895-8873
Practice Address - Street 1:3638 IRENE ST
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-2127
Practice Address - Country:US
Practice Address - Phone:734-405-0846
Practice Address - Fax:734-895-8873
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-06
Last Update Date:2018-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS820295801320800000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness