Healthcare Provider Details

I. General information

NPI: 1275802647
Provider Name (Legal Business Name): LOVE KNOT MEDICAL CENTER,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2011
Last Update Date: 12/14/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17234 GODDARD RD
ALLEN PARK MI
48101-4100
US

IV. Provider business mailing address

17234 GODDARD RD
ALLEN PARK MI
48101-4100
US

V. Phone/Fax

Practice location:
  • Phone: 313-627-1422
  • Fax:
Mailing address:
  • Phone: 313-627-1422
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QP3300X
TaxonomyPain Clinic/Center
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code261QR0400X
TaxonomyRehabilitation Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: KANISHA BREWER
Title or Position: ADMINSTRATOR
Credential:
Phone: 313-627-1422