Healthcare Provider Details

I. General information

NPI: 1649677873
Provider Name (Legal Business Name): CENTRIA HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/03/2014
Last Update Date: 12/03/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7893 HARDING ST
TAYLOR MI
48180-2535
US

IV. Provider business mailing address

7893 HARDING ST
TAYLOR MI
48180-2535
US

V. Phone/Fax

Practice location:
  • Phone: 313-316-0923
  • Fax:
Mailing address:
  • Phone: 313-316-0923
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number5202001741
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number5202001741
License Number StateMI

VIII. Authorized Official

Name: MRS. MARIANNE DENISE RODEN
Title or Position: COTA/L
Credential: COTA/L
Phone: 313-316-0923