Healthcare Provider Details

I. General information

NPI: 1831511393
Provider Name (Legal Business Name): LIFESTYLES SUPPORTIVE LIVING SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2014
Last Update Date: 04/19/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2370 E STADIUM BLVD # 640
ANN ARBOR MI
48104-4811
US

IV. Provider business mailing address

2370 E STADIUM BLVD # 640
ANN ARBOR MI
48104-4811
US

V. Phone/Fax

Practice location:
  • Phone: 734-726-4086
  • Fax:
Mailing address:
  • Phone: 734-726-4086
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number StateMI
# 5
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. MANUEL DEWITT THOMAS JR.
Title or Position: ADMINISTRATOR
Credential:
Phone: 734-726-4086