Provider Demographics
NPI:1639320708
Name:BURNETT AFC
Entity Type:Organization
Organization Name:BURNETT AFC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:DANA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BURNETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-743-6291
Mailing Address - Street 1:2181 KENNETH ST
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-1358
Mailing Address - Country:US
Mailing Address - Phone:810-743-6291
Mailing Address - Fax:810-743-1579
Practice Address - Street 1:2181 KENNETH ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1358
Practice Address - Country:US
Practice Address - Phone:810-743-6291
Practice Address - Fax:810-743-1579
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-07
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM250067081320800000X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5294486Medicaid