Provider Demographics
NPI:1679881478
Name:WAYNE COUNTY JUVENILE DETENTION FACILITY
Entity type:Organization
Organization Name:WAYNE COUNTY JUVENILE DETENTION FACILITY
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TADARIAL
Authorized Official - Middle Name:
Authorized Official - Last Name:STURDIVANT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-833-7125
Mailing Address - Street 1:1326 SAINT ANTOINE ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48226-2301
Mailing Address - Country:US
Mailing Address - Phone:313-967-2050
Mailing Address - Fax:313-967-6552
Practice Address - Street 1:1326 SAINT ANTOINE ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48226-2301
Practice Address - Country:US
Practice Address - Phone:313-967-2050
Practice Address - Fax:313-967-6552
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WAYNE COUNTY
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2010-09-15
Last Update Date:2010-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICE820201498311Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility