Healthcare Provider Details

I. General information

NPI: 1033988407
Provider Name (Legal Business Name): SULLIVAN LIFESTYLE SOLUTIONS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/27/2023
Last Update Date: 12/27/2023
Certification Date: 12/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24123 GREENFIELD RD STE 306
SOUTHFIELD MI
48075-3124
US

IV. Provider business mailing address

28401 MOUND RD UNIT 1664
WARREN MI
48090-7259
US

V. Phone/Fax

Practice location:
  • Phone: 248-275-3870
  • Fax: 248-918-4337
Mailing address:
  • Phone: 248-275-3870
  • Fax: 248-918-4337

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: TALIA SIMONE AZIR
Title or Position: MANAGING MANAGER
Credential: MSW
Phone: 248-275-3870