Provider Demographics
NPI:1598831786
Name:PROFESSIONAL ASSISTED LIVING INC
Entity Type:Organization
Organization Name:PROFESSIONAL ASSISTED LIVING INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADM OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:ANITA
Authorized Official - Middle Name:F
Authorized Official - Last Name:TANG
Authorized Official - Suffix:
Authorized Official - Credentials:RN BSN
Authorized Official - Phone:248-626-0803
Mailing Address - Street 1:30800 TELEGRAPH ROAD
Mailing Address - Street 2:SUITE 1710
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025
Mailing Address - Country:US
Mailing Address - Phone:248-282-0221
Mailing Address - Fax:248-282-0223
Practice Address - Street 1:6508 CATHEDRAL DRIVE
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48301-3043
Practice Address - Country:US
Practice Address - Phone:248-626-0803
Practice Address - Fax:248-626-1608
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI15432921Medicaid
237455Medicare ID - Type Unspecified
MI15432921Medicaid