Healthcare Provider Details

I. General information

NPI: 1548533896
Provider Name (Legal Business Name): LIFE CENTER MIHP
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/16/2012
Last Update Date: 02/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20245 PICADILLY RD
DETROIT MI
48221-1308
US

IV. Provider business mailing address

20245 PICADILLY RD
DETROIT MI
48221-1308
US

V. Phone/Fax

Practice location:
  • Phone: 313-704-4837
  • Fax:
Mailing address:
  • Phone: 313-704-4837
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: KRYSTAL LYN COPELAND
Title or Position: OWNER
Credential: LLMSW
Phone: 313-704-4837