Provider Demographics
NPI:1780996926
Name:KOUROUMA SERVICES LLC
Entity type:Organization
Organization Name:KOUROUMA SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MRS
Authorized Official - First Name:CHANTELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MORRISON-KOUROUMA
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MED
Authorized Official - Phone:313-402-7812
Mailing Address - Street 1:PO BOX 8235
Mailing Address - Street 2:
Mailing Address - City:EASTPOINTE
Mailing Address - State:MI
Mailing Address - Zip Code:48021-8235
Mailing Address - Country:US
Mailing Address - Phone:313-402-7812
Mailing Address - Fax:
Practice Address - Street 1:13560 E MCNICHOLS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48205-3426
Practice Address - Country:US
Practice Address - Phone:313-402-7812
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-03
Last Update Date:2012-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704258152251B00000X, 251J00000X, 251S00000X, 251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
No251B00000XAgenciesCase Management
No251J00000XAgenciesNursing Care
No251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2249265Medicaid
MI1316273030Medicaid