Provider Demographics
NPI:1124310818
Name:HERNANDEZ HOME LLC
Entity type:Organization
Organization Name:HERNANDEZ HOME LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRACIE
Authorized Official - Middle Name:
Authorized Official - Last Name:HERNANDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-628-2100
Mailing Address - Street 1:P.O. BOX 277
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGDALE
Mailing Address - State:MI
Mailing Address - Zip Code:49026
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:94 45TH ST
Practice Address - Street 2:
Practice Address - City:BLOOMINGDALE
Practice Address - State:MI
Practice Address - Zip Code:49026-9502
Practice Address - Country:US
Practice Address - Phone:269-628-2100
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-05-12
Last Update Date:2011-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS030282002320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities