Provider Demographics
NPI:1790585206
Name:AGING SUPERBLY LLC
Entity type:Organization
Organization Name:AGING SUPERBLY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:PETRINA
Authorized Official - Middle Name:
Authorized Official - Last Name:GONDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-402-1158
Mailing Address - Street 1:3510 HELEN AVE
Mailing Address - Street 2:
Mailing Address - City:LINCOLN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48146-3462
Mailing Address - Country:US
Mailing Address - Phone:313-402-1158
Mailing Address - Fax:
Practice Address - Street 1:3510 HELEN AVE
Practice Address - Street 2:
Practice Address - City:LINCOLN PARK
Practice Address - State:MI
Practice Address - Zip Code:48146-3462
Practice Address - Country:US
Practice Address - Phone:313-402-1158
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-03-14
Last Update Date:2025-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health