Healthcare Provider Details

I. General information

NPI: 1750457958
Provider Name (Legal Business Name): KAIROS HEALTHCARE INCORPORATED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2006
Last Update Date: 08/27/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

20400 SUPERIOR RD
TAYLOR MI
48180-5362
US

IV. Provider business mailing address

6379 DIXIE HWY
BRIDGEPORT MI
48722-9566
US

V. Phone/Fax

Practice location:
  • Phone: 734-374-2400
  • Fax: 734-374-8360
Mailing address:
  • Phone: 989-777-4357
  • Fax: 989-777-7257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number823011
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number823011
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number823011
License Number StateMI

VIII. Authorized Official

Name: MR. FRED E. WIGEN JR.
Title or Position: PRESIDENT CEO
Credential:
Phone: 989-777-4357