Provider Demographics
NPI:1417333931
Name:GILBERT
Entity Type:Organization
Organization Name:GILBERT
Other - Org Name:SELF
Other - Org Type:Other Name
Authorized Official - Title/Position:CARE GIVER
Authorized Official - Prefix:MR
Authorized Official - First Name:GILBERT
Authorized Official - Middle Name:J
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-850-5205
Mailing Address - Street 1:15800 FAIRMOUNT DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48205-1448
Mailing Address - Country:US
Mailing Address - Phone:313-850-5205
Mailing Address - Fax:
Practice Address - Street 1:15800 FAIRMOUNT DR
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-1448
Practice Address - Country:US
Practice Address - Phone:313-850-5205
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:SELF
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-08-06
Last Update Date:2015-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care