Healthcare Provider Details

I. General information

NPI: 1891988937
Provider Name (Legal Business Name): LIGHT OF RECOVERY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/22/2007
Last Update Date: 07/02/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2008 W GRAND BLVD
DETROIT MI
48208-1021
US

IV. Provider business mailing address

2008 W GRAND BLVD
DETROIT MI
48208-1021
US

V. Phone/Fax

Practice location:
  • Phone: 313-898-5938
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number6801015887
License Number StateMI

VIII. Authorized Official

Name: SERVILLA HARRIS
Title or Position: SOCIAL WORKER
Credential:
Phone: 313-898-5938