Basic Information
| Provider Information | |||||||||
| NPI: | 1548533896 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LIFE CENTER MIHP | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 20245 PICADILLY RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482211308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137044837 | ||||||||
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| Practice Location | |||||||||
| Address1: | 20245 PICADILLY RD | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482211308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3137044837 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/16/2012 | ||||||||
| LastUpdateDate: | 02/16/2012 | ||||||||
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| AuthorizedOfficialLastName: | COPELAND | ||||||||
| AuthorizedOfficialFirstName: | KRYSTAL | ||||||||
| AuthorizedOfficialMiddleName: | LYN | ||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 3137044837 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | LLMSW | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | Y | Agencies | In Home Supportive Care |
No ID Information.