Healthcare Provider Details

I. General information

NPI: 1982957627
Provider Name (Legal Business Name): ABYSSINIA LOVE KNOT POST TRAUMA CARE,LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2012
Last Update Date: 10/18/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18591 W 10 MILE RD STE 4
SOUTHFIELD MI
48075-2619
US

IV. Provider business mailing address

18591 W 10 MILE RD STE 4
SOUTHFIELD MI
48075-2619
US

V. Phone/Fax

Practice location:
  • Phone: 248-262-7914
  • Fax:
Mailing address:
  • Phone: 248-262-7914
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. SAMANTHA TURNER
Title or Position: MANAGER
Credential:
Phone: 248-262-7914