Provider Demographics
NPI:1629050471
Name:MANNA OF DETROIT INC.
Entity Type:Organization
Organization Name:MANNA OF DETROIT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARVIN
Authorized Official - Middle Name:CHILES
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:
Authorized Official - Credentials:MA CACII NCGC SWT
Authorized Official - Phone:313-491-2956
Mailing Address - Street 1:PO BOX 20696
Mailing Address - Street 2:12048 GRAND RIVER, DET.MI 48204
Mailing Address - City:FERNDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48220-0696
Mailing Address - Country:US
Mailing Address - Phone:313-491-2956
Mailing Address - Fax:313-491-0616
Practice Address - Street 1:12048 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-1836
Practice Address - Country:US
Practice Address - Phone:313-491-2956
Practice Address - Fax:313-491-0616
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-17
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI822416101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)Group - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0897365Medicare UPIN
MI0N78980Medicare ID - Type Unspecified