Healthcare Provider Details

I. General information

NPI: 1427162239
Provider Name (Legal Business Name): KAIROS HEALTHCARE INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/18/2006
Last Update Date: 01/02/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6379 DIXIE HWY
BRIDGEPORT MI
48722-9566
US

IV. Provider business mailing address

6379 DIXIE HWY
BRIDGEPORT MI
48722-9566
US

V. Phone/Fax

Practice location:
  • Phone: 989-777-4357
  • Fax: 989-777-7257
Mailing address:
  • Phone: 989-777-4357
  • Fax: 989-777-7257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number730157
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number730157
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number730157
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code3245S0500X
TaxonomyChildren's Substance Abuse Rehabilitation Facility
License Number730157
License Number StateMI

VIII. Authorized Official

Name: MR. FRED E. WIGEN JR.
Title or Position: PRESIDENT/CEO
Credential:
Phone: 989-777-4357