Healthcare Provider Details

I. General information

NPI: 1316996226
Provider Name (Legal Business Name): WOODHAVEN OF LIVONIA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/08/2006
Last Update Date: 06/23/2023
Certification Date: 06/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29667 WENTWORTH ST
LIVONIA MI
48154-6231
US

IV. Provider business mailing address

29667 WENTWORTH ST
LIVONIA MI
48154-6231
US

V. Phone/Fax

Practice location:
  • Phone: 734-261-9000
  • Fax: 734-261-9003
Mailing address:
  • Phone: 734-261-9000
  • Fax: 734-261-9003

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number824514
License Number StateMI

VIII. Authorized Official

Name: MR. RANDALL W. GASSER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 734-261-9000