Basic Information
| Provider Information | |||||||||
| NPI: | 1730586710 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CENTRIA HEALTHCARE LLC | ||||||||
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| OtherOrganizationName: | CENTRIA HEALTHCARE - DEARBORN CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 41521 W 11 MILE RD | ||||||||
| Address2: | |||||||||
| City: | NOVI | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483751803 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482990030 | ||||||||
| FaxNumber: | 2489121566 | ||||||||
| Practice Location | |||||||||
| Address1: | 19855 OUTER DR | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | DEARBORN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481242022 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482990030 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/19/2014 | ||||||||
| LastUpdateDate: | 12/09/2014 | ||||||||
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| AuthorizedOfficialLastName: | WILCOX | ||||||||
| AuthorizedOfficialFirstName: | CHRISTOPHER | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2482990030 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0855X | Y | Ambulatory Health Care Facilities | Clinic/Center | Adolescent and Children Mental Health |
No ID Information.