Basic Information
Provider Information | |||||||||
NPI: | 1316410681 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THE LIGHT TREATMENT & REHABILITATION LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 6269 POTOMAC CIR | ||||||||
Address2: |   | ||||||||
City: | WEST BLOOMFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 483222125 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2484958985 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 5380 KREGER ST | ||||||||
Address2: |   | ||||||||
City: | STERLING HEIGHTS | ||||||||
State: | MI | ||||||||
PostalCode: | 483105728 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2484958985 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/09/2019 | ||||||||
LastUpdateDate: | 01/09/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | CARTER | ||||||||
AuthorizedOfficialFirstName: | KARICIA | ||||||||
AuthorizedOfficialMiddleName: | R | ||||||||
AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
AuthorizedOfficialTelephone: | 2484958985 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 324500000X |   |   | N |   | Residential Treatment Facilities | Substance Abuse Rehabilitation Facility |   | 323P00000X |   |   | Y |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   |
No ID Information.