Provider Demographics
NPI:1609209634
Name:DETROIT FAMILY HOME
Entity Type:Organization
Organization Name:DETROIT FAMILY HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JEAN
Authorized Official - Middle Name:FELIX
Authorized Official - Last Name:NYAMBIO
Authorized Official - Suffix:
Authorized Official - Credentials:CRNA
Authorized Official - Phone:301-332-3009
Mailing Address - Street 1:17180 INDIANA ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2445
Mailing Address - Country:US
Mailing Address - Phone:313-270-7751
Mailing Address - Fax:313-270-7291
Practice Address - Street 1:17180 INDIANA ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2445
Practice Address - Country:US
Practice Address - Phone:313-270-7751
Practice Address - Fax:313-270-7291
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-13
Last Update Date:2017-12-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS820338244311Z00000X, 311ZA0620X, 320600000X, 320700000X, 320800000X, 385H00000X, 385HR2060X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
No385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child