Basic Information
Provider Information | |||||||||
NPI: | 1699982314 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ALTERNATIVE COMMUNITY LIVING INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | NEW PASSAGES | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 70 LAFAYETTE ST | ||||||||
Address2: |   | ||||||||
City: | PONTIAC | ||||||||
State: | MI | ||||||||
PostalCode: | 483422033 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483387458 | ||||||||
FaxNumber: | 2483387513 | ||||||||
Practice Location | |||||||||
Address1: | 34294 MAPLE LANE DR | ||||||||
Address2: |   | ||||||||
City: | STERLING HEIGHTS | ||||||||
State: | MI | ||||||||
PostalCode: | 483125211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 5867954734 | ||||||||
FaxNumber: | 5867954912 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/16/2007 | ||||||||
LastUpdateDate: | 04/28/2011 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JACOBS | ||||||||
AuthorizedOfficialFirstName: | DENNIS | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 2483387458 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | DR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | PHD | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320600000X | AS500015534 | MI | Y |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   |
No ID Information.