Healthcare Provider Details

I. General information

NPI: 1174374797
Provider Name (Legal Business Name): SOUL FORWARD SOBER COMPANIONS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/01/2024
Last Update Date: 02/07/2025
Certification Date: 02/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4000 TOWN CTR STE 1303
SOUTHFIELD MI
48075-1410
US

IV. Provider business mailing address

133 E GRAND BLVD APT 208
DETROIT MI
48207-3777
US

V. Phone/Fax

Practice location:
  • Phone: 248-932-4000
  • Fax:
Mailing address:
  • Phone: 586-339-2178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: MR. CLAUDE GRACY JR.
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 586-339-2178