Provider Demographics
NPI:1659621597
Name:BOYS TO MEN GROUP HOME, LLC
Entity Type:Organization
Organization Name:BOYS TO MEN GROUP HOME, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CO-OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ANTHONY
Authorized Official - Middle Name:
Authorized Official - Last Name:POPLAR
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-998-9343
Mailing Address - Street 1:6025 LITCHFIELD LN
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49009-9128
Mailing Address - Country:US
Mailing Address - Phone:269-254-8444
Mailing Address - Fax:
Practice Address - Street 1:6025 LITCHFIELD LN
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49009-9128
Practice Address - Country:US
Practice Address - Phone:269-254-8444
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-18
Last Update Date:2012-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes322D00000XResidential Treatment FacilitiesResidential Treatment Facility, Emotionally Disturbed Children