Provider Demographics
NPI:1336732585
Name:KTJ HOME CARE AGENCY LLC
Entity Type:Organization
Organization Name:KTJ HOME CARE AGENCY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SHERIE
Authorized Official - Middle Name:M
Authorized Official - Last Name:TATUM
Authorized Official - Suffix:
Authorized Official - Credentials:HOME MAKER SERVICES
Authorized Official - Phone:313-412-2372
Mailing Address - Street 1:17249 SUNDERLAND RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219-4203
Mailing Address - Country:US
Mailing Address - Phone:313-412-2372
Mailing Address - Fax:
Practice Address - Street 1:17249 SUNDERLAND RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48219-4203
Practice Address - Country:US
Practice Address - Phone:313-412-2372
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-18
Last Update Date:2021-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
No253Z00000XAgenciesIn Home Supportive Care
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility