Provider Demographics
NPI:1629056486
Name:MACOMB COUNTY HUMAN SERVICES BOARD-AN AGENCY OF MACOMB COUNTY
Entity Type:Organization
Organization Name:MACOMB COUNTY HUMAN SERVICES BOARD-AN AGENCY OF MACOMB COUNTY
Other - Org Name:MARTHA T. BERRY MCF
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:
Authorized Official - Last Name:MORGAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-469-5623
Mailing Address - Street 1:43533 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:MOUNT CLEMENS
Mailing Address - State:MI
Mailing Address - Zip Code:48043-1034
Mailing Address - Country:US
Mailing Address - Phone:586-469-5265
Mailing Address - Fax:586-466-7418
Practice Address - Street 1:43533 ELIZABETH ST
Practice Address - Street 2:
Practice Address - City:MOUNT CLEMENS
Practice Address - State:MI
Practice Address - Zip Code:48043-1034
Practice Address - Country:US
Practice Address - Phone:586-469-5265
Practice Address - Fax:586-466-7418
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2015-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI508510314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2085301Medicaid
MI2085301Medicaid