Healthcare Provider Details

I. General information

NPI: 1144469461
Provider Name (Legal Business Name): LAKERIDGE VILLAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2009
Last Update Date: 01/26/2026
Certification Date: 01/26/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15941 FAIRFIELD ST
DETROIT MI
48238-4123
US

IV. Provider business mailing address

15025 FENKELL ST
DETROIT MI
48227-2647
US

V. Phone/Fax

Practice location:
  • Phone: 313-345-4310
  • Fax: 313-345-4315
Mailing address:
  • Phone: 313-345-4310
  • Fax: 313-345-4315

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code177F00000X
TaxonomyLodging Provider
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251V00000X
TaxonomyVoluntary or Charitable Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License Number822985
License Number StateMI
# 7
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: EUGENIA HOLIMON
Title or Position: CHIEF OF STAFF
Credential:
Phone: 313-340-2808