Healthcare Provider Details

I. General information

NPI: 1366926719
Provider Name (Legal Business Name): LEWISITE INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2018
Last Update Date: 09/21/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

424 SAINT JOHN ST
WYANDOTTE MI
48192-2947
US

IV. Provider business mailing address

424 SAINT JOHN ST
WYANDOTTE MI
48192-2947
US

V. Phone/Fax

Practice location:
  • Phone: 248-761-7452
  • Fax:
Mailing address:
  • Phone: 248-761-7452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: CHARLOTTE COLEMAN
Title or Position: CEO
Credential:
Phone: 248-761-7452