Provider Demographics
NPI:1528202512
Name:HOME COMMUNITY SUPPORTED LIVING ARRANGEMENTS
Entity Type:Organization
Organization Name:HOME COMMUNITY SUPPORTED LIVING ARRANGEMENTS
Other - Org Name:HOME, INC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:REXINE
Authorized Official - Middle Name:
Authorized Official - Last Name:NEWHOUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-242-2177
Mailing Address - Street 1:852 W ELM AVE
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:MI
Mailing Address - Zip Code:48162-7917
Mailing Address - Country:US
Mailing Address - Phone:734-242-2177
Mailing Address - Fax:734-242-2523
Practice Address - Street 1:852 W ELM AVE
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:MI
Practice Address - Zip Code:48162-7917
Practice Address - Country:US
Practice Address - Phone:734-242-2177
Practice Address - Fax:734-242-2523
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2009-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2812326OtherODJFS MEDICAID PROVIDER NUMBER