Provider Demographics
NPI:1376816611
Name:HURON PERSONAL CARE HOME
Entity Type:Organization
Organization Name:HURON PERSONAL CARE HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PROVIDER/OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:LOTTIE
Authorized Official - Middle Name:GRACE
Authorized Official - Last Name:CAFFEE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-332-1780
Mailing Address - Street 1:350 W HURON ST
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48341-1422
Mailing Address - Country:US
Mailing Address - Phone:248-332-1780
Mailing Address - Fax:248-332-1710
Practice Address - Street 1:350 W HURON ST
Practice Address - Street 2:
Practice Address - City:PONTIAC
Practice Address - State:MI
Practice Address - Zip Code:48341-1422
Practice Address - Country:US
Practice Address - Phone:248-332-1780
Practice Address - Fax:248-332-1710
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-02-16
Last Update Date:2012-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM630009309311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2118627Medicaid