Provider Demographics
NPI:1790056448
Name:DYVERSE MANAGEMENT, LLC
Entity Type:Organization
Organization Name:DYVERSE MANAGEMENT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-910-6878
Mailing Address - Street 1:28475 GREENFIELD RD
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48076-3034
Mailing Address - Country:US
Mailing Address - Phone:248-910-6878
Mailing Address - Fax:248-352-5389
Practice Address - Street 1:28475 GREENFIELD RD
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48076-3034
Practice Address - Country:US
Practice Address - Phone:248-910-6878
Practice Address - Fax:248-352-5389
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-01-25
Last Update Date:2012-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2=========Medicaid