Healthcare Provider Details

I. General information

NPI: 1619739273
Provider Name (Legal Business Name): PHRI OF MICHIGAN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/29/2024
Last Update Date: 01/29/2024
Certification Date: 01/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 W GRAND BLVD
DETROIT MI
48208-1236
US

IV. Provider business mailing address

2501 W GRAND BLVD
DETROIT MI
48208-1236
US

V. Phone/Fax

Practice location:
  • Phone: 248-252-7050
  • Fax:
Mailing address:
  • Phone: 248-252-7050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: JOHN SMITH
Title or Position: CEO
Credential:
Phone: 240-644-3578