Provider Demographics
NPI:1497058549
Name:CLW ADULT DAY CARE SERVICE LLC
Entity Type:Organization
Organization Name:CLW ADULT DAY CARE SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:C.E.O
Authorized Official - Prefix:MS
Authorized Official - First Name:NAKEYSHA
Authorized Official - Middle Name:CATHERINE
Authorized Official - Last Name:WISDOM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-575-3573
Mailing Address - Street 1:10450 W JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVER ROUGE
Mailing Address - State:MI
Mailing Address - Zip Code:48218-1334
Mailing Address - Country:US
Mailing Address - Phone:313-575-3573
Mailing Address - Fax:313-842-0066
Practice Address - Street 1:10450 W JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:RIVER ROUGE
Practice Address - State:MI
Practice Address - Zip Code:48218-1334
Practice Address - Country:US
Practice Address - Phone:313-575-3573
Practice Address - Fax:313-842-0066
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-12-13
Last Update Date:2010-12-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care