Healthcare Provider Details

I. General information

NPI: 1669386603
Provider Name (Legal Business Name): SOUL4REAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/29/2026
Last Update Date: 09/29/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

29673 NORTHWESTERN HWY
SOUTHFIELD MI
48034-1033
US

IV. Provider business mailing address

286 ALHAMBRA ST
PONTIAC MI
48341-1090
US

V. Phone/Fax

Practice location:
  • Phone: 248-629-0050
  • Fax:
Mailing address:
  • Phone: 313-575-6229
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code132700000X
TaxonomyDietary Manager
License Number
License Number StateNULL

VIII. Authorized Official

Name: TINA L PHILLIPS
Title or Position: CFO
Credential: OWNER
Phone: 313-575-6229