Provider Demographics
NPI:1801670237
Name:OFFICIAL CARE CONNECTION LLC
Entity type:Organization
Organization Name:OFFICIAL CARE CONNECTION LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OPERATING CARE PROVIDER
Authorized Official - Prefix:MR
Authorized Official - First Name:HEZEKIAH
Authorized Official - Middle Name:DWAYNE
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-717-2598
Mailing Address - Street 1:2222 FERRY PARK ST # 1206
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1384
Mailing Address - Country:US
Mailing Address - Phone:313-639-8117
Mailing Address - Fax:
Practice Address - Street 1:25296 RONALD ST
Practice Address - Street 2:
Practice Address - City:ROSEVILLE
Practice Address - State:MI
Practice Address - Zip Code:48066-4461
Practice Address - Country:US
Practice Address - Phone:313-717-2598
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ONLY FAMILY CONNECTIONS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2023-08-24
Last Update Date:2023-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI8132125Medicaid