Provider Demographics
NPI:1760979959
Name:MY PLACE AFC
Entity Type:Organization
Organization Name:MY PLACE AFC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:M
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-510-2879
Mailing Address - Street 1:15565 NORTHLAND DR E STE 901
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-5331
Mailing Address - Country:US
Mailing Address - Phone:248-559-5683
Mailing Address - Fax:
Practice Address - Street 1:21415 SHERMAN AVE
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48033-4388
Practice Address - Country:US
Practice Address - Phone:313-510-2879
Practice Address - Fax:248-559-5692
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-04-13
Last Update Date:2018-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172V00000XOther Service ProvidersCommunity Health WorkerGroup - Multi-Specialty