Healthcare Provider Details

I. General information

NPI: 1104585421
Provider Name (Legal Business Name): BWC BRIGHTON LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 11/02/2022
Certification Date: 11/02/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8175 MOVIE DR
BRIGHTON MI
48116-7444
US

IV. Provider business mailing address

8175 MOVIE DR
BRIGHTON MI
48116-7444
US

V. Phone/Fax

Practice location:
  • Phone: 248-277-3005
  • Fax: 248-277-3050
Mailing address:
  • Phone: 248-277-3005
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261QX0100X
TaxonomyOccupational Medicine Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ZIAD KOZA
Title or Position: OWNER
Credential:
Phone: 248-860-6212