Basic Information
Provider Information | |||||||||
NPI: | 1730757261 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | MORIAH ENRICHMENT CENTER, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 6069 | ||||||||
Address2: |   | ||||||||
City: | ANN ARBOR | ||||||||
State: | MI | ||||||||
PostalCode: | 481066069 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7346770070 | ||||||||
FaxNumber: | 7346770890 | ||||||||
Practice Location | |||||||||
Address1: | 8735 MI STATE ROAD 52 | ||||||||
Address2: |   | ||||||||
City: | MANCHESTER | ||||||||
State: | MI | ||||||||
PostalCode: | 481589445 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7344280369 | ||||||||
FaxNumber: | 7344280408 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/11/2021 | ||||||||
LastUpdateDate: | 07/22/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | TROJANEK | ||||||||
AuthorizedOfficialFirstName: | CHARLES | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | DIRECTOR OF FINANCE | ||||||||
AuthorizedOfficialTelephone: | 7346770070 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/22/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251C00000X |   |   | N |   | Agencies | Day Training, Developmentally Disabled Services |   | 251S00000X |   |   | N |   | Agencies | Community/Behavioral Health |   | 261QD1600X |   |   | N |   | Ambulatory Health Care Facilities | Clinic/Center | Developmental Disabilities | 320600000X |   |   | N |   | Residential Treatment Facilities | Residential Treatment Facility, Mental Retardation and/or Developmental Disabilities |   | 320700000X |   |   | N |   | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities |   | 320900000X |   |   | N |   | Residential Treatment Facilities | Community Based Residential Treatment, Mental Retardation and/or Developmental Disabilities |   | 261QM1300X |   |   | Y |   | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.