Provider Demographics
NPI:1922401744
Name:DOMINION ADULT DAY CARE AND THERAPEUTIC CLINIC
Entity Type:Organization
Organization Name:DOMINION ADULT DAY CARE AND THERAPEUTIC CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BILLIE
Authorized Official - Middle Name:R
Authorized Official - Last Name:SMITH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-586-2249
Mailing Address - Street 1:12601 E CANFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48215-2210
Mailing Address - Country:US
Mailing Address - Phone:313-586-2249
Mailing Address - Fax:
Practice Address - Street 1:12601 E CANFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48215-2210
Practice Address - Country:US
Practice Address - Phone:313-586-2249
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-10-07
Last Update Date:2015-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI68010207671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIMI8121Medicare PIN