Provider Demographics
NPI:1669674917
Name:DERRICK'S ADULT FOSTER CARE INC
Entity Type:Organization
Organization Name:DERRICK'S ADULT FOSTER CARE INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT, CEO, LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:CASSANDRA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DERRICK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-640-4813
Mailing Address - Street 1:PO BOX 252983
Mailing Address - Street 2:
Mailing Address - City:WEST BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48325-2983
Mailing Address - Country:US
Mailing Address - Phone:248-640-4813
Mailing Address - Fax:248-661-5024
Practice Address - Street 1:5004 31ST ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48210-2537
Practice Address - Country:US
Practice Address - Phone:313-897-3385
Practice Address - Fax:248-661-5024
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-31
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home