Basic Information
| Provider Information | |||||||||
| NPI: | 1013585405 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MORIAH, INCORPORATED | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3200 E EISENHOWER PKWY | ||||||||
| Address2: | |||||||||
| City: | ANN ARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481083231 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346770070 | ||||||||
| FaxNumber: | 7346770890 | ||||||||
| Practice Location | |||||||||
| Address1: | 29991 MITCHELL ST | ||||||||
| Address2: | |||||||||
| City: | SELFRIDGE ANGB | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480454957 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7346770070 | ||||||||
| FaxNumber: | 7346770890 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/14/2021 | ||||||||
| LastUpdateDate: | 06/14/2021 | ||||||||
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| AuthorizedOfficialLastName: | MUCHA | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | COMPLIANCE AND CONTRACTS MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 7346770070 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | MORIAH INC. | ||||||||
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| AuthorizedOfficialCredential: | MHA | ||||||||
| NPICertificationDate: | 06/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 320700000X | N | Residential Treatment Facilities | Residential Treatment Facility, Physical Disabilities | 261QM0850X | N | Ambulatory Health Care Facilities | Clinic/Center | Adult Mental Health | 261QM1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Multi-Specialty |
No ID Information.