Provider Demographics
NPI:1336546589
Name:FIVE STAR RESIDENTIAL INC
Entity Type:Organization
Organization Name:FIVE STAR RESIDENTIAL INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:STAFF NURSE CARDIAC ICU
Authorized Official - Prefix:
Authorized Official - First Name:JUDITH
Authorized Official - Middle Name:
Authorized Official - Last Name:TANGUAKA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:248-421-2735
Mailing Address - Street 1:22190 SUSSEX ST
Mailing Address - Street 2:
Mailing Address - City:OAK PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48237-3509
Mailing Address - Country:US
Mailing Address - Phone:248-421-2735
Mailing Address - Fax:248-677-3082
Practice Address - Street 1:22190 SUSSEX ST
Practice Address - Street 2:
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-3509
Practice Address - Country:US
Practice Address - Phone:248-421-2735
Practice Address - Fax:248-677-3082
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS630352375253J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253J00000XAgenciesFoster Care Agency