Provider Demographics
NPI:1265091706
Name:FORE, TRESA DIANE
Entity type:Individual
Prefix:
First Name:TRESA
Middle Name:DIANE
Last Name:FORE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25900 GREENFIELD RD STE 326
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-1297
Mailing Address - Country:US
Mailing Address - Phone:877-488-9724
Mailing Address - Fax:
Practice Address - Street 1:25900 GREENFIELD RD STE 326
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1297
Practice Address - Country:US
Practice Address - Phone:877-488-9724
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-09
Last Update Date:2019-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIF600802143635172A00000X
372500000X, 374700000X, 3747A0650X, 376J00000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
No172A00000XOther Service ProvidersDriver
No372500000XNursing Service Related ProvidersChore Provider
No374700000XNursing Service Related ProvidersTechnician
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
No376J00000XNursing Service Related ProvidersHomemaker