Healthcare Provider Details

I. General information

NPI: 1528130325
Provider Name (Legal Business Name): RIVERVIEW LIFELINE CENTER PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/15/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7633 EAST JEFFERSON AVE
DETROIT MI
48214
US

IV. Provider business mailing address

22201 MOROSS RD
DETROIT MI
48236-2169
US

V. Phone/Fax

Practice location:
  • Phone: 847-388-2032
  • Fax: 847-388-2020
Mailing address:
  • Phone: 847-388-2032
  • Fax: 847-388-2020

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MR. RAFAL OBRZUT
Title or Position: CODING MANAGER
Credential:
Phone: 847-388-2032