Basic Information
| Provider Information | |||||||||
| NPI: | 1992455414 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SEASONS OF CHANGE CORF, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 27200 LAHSER RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342137 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 27200 LAHSER RD | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480342137 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2482089215 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/27/2022 | ||||||||
| LastUpdateDate: | 03/27/2022 | ||||||||
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| AuthorizedOfficialLastName: | MCCOLLUM | ||||||||
| AuthorizedOfficialFirstName: | BRUCE | ||||||||
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| AuthorizedOfficialTitleorPosition: | AUTHORIZED OFFICIAL | ||||||||
| AuthorizedOfficialTelephone: | 7348371048 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 03/27/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) |
No ID Information.