Provider Demographics
NPI:1780436691
Name:FIVE STAR MEDICAL LLC
Entity type:Organization
Organization Name:FIVE STAR MEDICAL LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MRS
Authorized Official - First Name:KADEJAH
Authorized Official - Middle Name:DORENA
Authorized Official - Last Name:COON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-407-2088
Mailing Address - Street 1:5260 IVANHOE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-3632
Mailing Address - Country:US
Mailing Address - Phone:313-407-2088
Mailing Address - Fax:
Practice Address - Street 1:5260 IVANHOE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-3632
Practice Address - Country:US
Practice Address - Phone:313-407-2088
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-04-03
Last Update Date:2024-04-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No253J00000XAgenciesFoster Care Agency
No253Z00000XAgenciesIn Home Supportive Care
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility