Provider Demographics
NPI:1689087504
Name:MY HOME AWAY FROM HOME RESIDENTIAL & PHYSICAL THERAPY
Entity Type:Organization
Organization Name:MY HOME AWAY FROM HOME RESIDENTIAL & PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/C.E.O
Authorized Official - Prefix:MISS
Authorized Official - First Name:STAR
Authorized Official - Middle Name:BILLY
Authorized Official - Last Name:SCHUMAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-989-7092
Mailing Address - Street 1:1155 W MCNICHOLS RD APT 106
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-2514
Mailing Address - Country:US
Mailing Address - Phone:313-989-7092
Mailing Address - Fax:
Practice Address - Street 1:1155 W MCNICHOLS RD APT 106
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-2514
Practice Address - Country:US
Practice Address - Phone:313-989-7092
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIE4609Q320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities