Basic Information
| Provider Information | |||||||||
| NPI: | 1447283239 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | RADAKOVIC KIDS CO INC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | STAR MANOR OF NORTHVILLE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 520 W MAIN STREET | ||||||||
| Address2: | PO BOX 206 | ||||||||
| City: | NORTHVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481670206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483494290 | ||||||||
| FaxNumber: | 2483491663 | ||||||||
| Practice Location | |||||||||
| Address1: | 520 W MAIN STREET | ||||||||
| Address2: | |||||||||
| City: | NORTHVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481670206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483494290 | ||||||||
| FaxNumber: | 2483491663 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/08/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | GABRIEL | ||||||||
| AuthorizedOfficialFirstName: | DIANA | ||||||||
| AuthorizedOfficialMiddleName: | MARIE | ||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR-CEO | ||||||||
| AuthorizedOfficialTelephone: | 2483494290 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | NHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 23-E281 | MI | Y | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |
ID Information
| ID | Type | State | Issuer | Description | 23-E281 | 05 | MI | MEDICAID |