Provider Demographics
NPI:1851107726
Name:MOMBA HOME CARE MICHIGAN, LLC
Entity type:Organization
Organization Name:MOMBA HOME CARE MICHIGAN, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NPI MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ELAZAR
Authorized Official - Middle Name:
Authorized Official - Last Name:HUISMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:404-418-7484
Mailing Address - Street 1:5565 GLENRIDGE CONNECTOR STE 500
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30342-4796
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3200 GREENFIELD RD STE 300
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48120-1805
Practice Address - Country:US
Practice Address - Phone:248-290-9621
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-05
Last Update Date:2025-05-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1265260566OtherMI CHOICE WAIVER