Basic Information
| Provider Information | |||||||||
| NPI: | 1063629681 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALTERNATIVE COMMUNITY LIVING INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NEW PASSAGES | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2347 HARRINGTON RD | ||||||||
| Address2: | |||||||||
| City: | CROSWELL | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484229409 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8108780084 | ||||||||
| FaxNumber: | 8108780085 | ||||||||
| Practice Location | |||||||||
| Address1: | 70 LAFAYETTE ST | ||||||||
| Address2: | |||||||||
| City: | PONTIAC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483422033 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483387458 | ||||||||
| FaxNumber: | 2483387513 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2007 | ||||||||
| LastUpdateDate: | 04/20/2011 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | JACOBS | ||||||||
| AuthorizedOfficialFirstName: | DENNIS | ||||||||
| AuthorizedOfficialMiddleName: | R | ||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2483387458 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | DR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | PHD | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | AS760260183 | MI | Y | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |
No ID Information.