Provider Demographics
NPI:1336674415
Name:EDUCATING U4 LIFE CDC
Entity Type:Organization
Organization Name:EDUCATING U4 LIFE CDC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:ALBERT
Authorized Official - Middle Name:EUGENE
Authorized Official - Last Name:MACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:877-267-3491
Mailing Address - Street 1:22503 GRAND RIVER AVE
Mailing Address - Street 2:SUITE 19653
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-5034
Mailing Address - Country:US
Mailing Address - Phone:877-267-3491
Mailing Address - Fax:
Practice Address - Street 1:19321 W CHICAGO ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48228-1739
Practice Address - Country:US
Practice Address - Phone:877-267-3491
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-04-26
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6801011686251S00000X
MI6801046708252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No252Y00000XAgenciesEarly Intervention Provider Agency