Provider Demographics
NPI:1902202716
Name:RESIDENTIAL HOME HEALTHCARE
Entity Type:Organization
Organization Name:RESIDENTIAL HOME HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE ASSISTANT
Authorized Official - Prefix:MR
Authorized Official - First Name:JEFF
Authorized Official - Middle Name:MICHEAL
Authorized Official - Last Name:MASTIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-751-0200
Mailing Address - Street 1:11477 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48093-2678
Mailing Address - Country:US
Mailing Address - Phone:586-751-0200
Mailing Address - Fax:586-751-0414
Practice Address - Street 1:11477 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48093-2678
Practice Address - Country:US
Practice Address - Phone:586-751-0200
Practice Address - Fax:586-751-0414
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-11-06
Last Update Date:2014-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5901000447261QP1100X
MI5901001570261QP1100X
MI5901000468261QP1100X
MI4301025138261QP2300X
MI4301046450261QP2300X
MI4301095717261QP2300X
MI5101006690261QP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QP1100XAmbulatory Health Care FacilitiesClinic/CenterPodiatric