Provider Demographics
NPI:1891094892
Name:BLUE LEAF HOMECARE, LLC
Entity type:Organization
Organization Name:BLUE LEAF HOMECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ CHIEF OPERATING OFFICER
Authorized Official - Prefix:MS
Authorized Official - First Name:TATISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:MILLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-405-7668
Mailing Address - Street 1:29488 WOODWARD AVE
Mailing Address - Street 2:#234
Mailing Address - City:ROYAL OAK
Mailing Address - State:MI
Mailing Address - Zip Code:48073-0903
Mailing Address - Country:US
Mailing Address - Phone:313-405-7668
Mailing Address - Fax:313-450-4321
Practice Address - Street 1:18701 GRAND RIVER AVE # 327
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48223-2214
Practice Address - Country:US
Practice Address - Phone:313-405-7668
Practice Address - Fax:313-450-4321
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-03-16
Last Update Date:2012-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No385H00000XRespite Care FacilityRespite Care
No385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child