Healthcare Provider Details

I. General information

NPI: 1982754024
Provider Name (Legal Business Name): LIFE SKILLS CENTERS, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/11/2007
Last Update Date: 10/25/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

53 CROCKER
MT. CLEMENS MI
48043-2550
US

IV. Provider business mailing address

53 CROCKER BLVD
MOUNT CLEMENS MI
48043-2550
US

V. Phone/Fax

Practice location:
  • Phone: 586-468-3682
  • Fax: 586-468-3694
Mailing address:
  • Phone: 586-468-3682
  • Fax: 586-468-3694

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. DALE R. WAGNER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 586-468-3682