Provider Demographics
NPI:1871327999
Name:INTENTIONAL CARE SERVICE
Entity type:Organization
Organization Name:INTENTIONAL CARE SERVICE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DOMINIQUE
Authorized Official - Middle Name:
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:313-398-4275
Mailing Address - Street 1:11000 W MCNICHOLS RD STE 323-1263
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-2357
Mailing Address - Country:US
Mailing Address - Phone:313-398-4275
Mailing Address - Fax:
Practice Address - Street 1:11000 W MCNICHOLS RD STE 323-1263
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48221-2357
Practice Address - Country:US
Practice Address - Phone:313-398-4275
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-08-30
Last Update Date:2024-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health