Provider Demographics
NPI:1790936607
Name:MCMAHAN ADULT FOSTER CARE
Entity Type:Organization
Organization Name:MCMAHAN ADULT FOSTER CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TRACY
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:MCMAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-875-9681
Mailing Address - Street 1:1478 E BUDER AVE
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-1606
Mailing Address - Country:US
Mailing Address - Phone:810-875-9681
Mailing Address - Fax:810-875-9681
Practice Address - Street 1:1478 E BUDER AVE
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-1606
Practice Address - Country:US
Practice Address - Phone:810-875-9681
Practice Address - Fax:810-875-9681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-09
Last Update Date:2008-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS250285536101YM0800X, 320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAS250285536Medicaid