Healthcare Provider Details

I. General information

NPI: 1972535474
Provider Name (Legal Business Name): MILLENNIUM TREATMENT SERVICES, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/07/2006
Last Update Date: 11/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 E 12 MILE RD
MADISON HEIGHTS MI
48071-2651
US

IV. Provider business mailing address

1400 E 12 MILE RD
MADISON HEIGHTS MI
48071-2651
US

V. Phone/Fax

Practice location:
  • Phone: 248-547-2223
  • Fax: 248-547-2226
Mailing address:
  • Phone: 248-547-2223
  • Fax: 248-547-2226

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number500371
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code261QM2800X
TaxonomyMethadone Clinic
License Number631090
License Number StateMI

VIII. Authorized Official

Name: ANTHONY COSIMO CLEMENTE
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 248-932-3412