# HERNANDEZ HOME LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1124310818
- **Authorized official:** TRACIE HERNANDEZ (CEO)
- **Authorized official phone:** (269) 628-2100

## Contact information

- **Practice address:** 94 45TH ST, BLOOMINGDALE, MI 49026-9502
- **Practice address phone:** (269) 628-2100
- **Mailing address:** P.O. BOX 277, BLOOMINGDALE, MI 49026

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 320600000X | Intellectual and/or Developmental Disabilities Residential Treatment Facility | AS030282002 | MI | Yes |

## Other

- **Enumeration date:** 05/12/2011
- **Last updated:** 05/12/2011