Healthcare Provider Details

I. General information

NPI: 1609825124
Provider Name (Legal Business Name): SYNOD RESIDENTIAL SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/10/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

615 S MANSFIELD ST
YPSILANTI MI
48197-5156
US

IV. Provider business mailing address

PO BOX 980465
YPSILANTI MI
48198-0465
US

V. Phone/Fax

Practice location:
  • Phone: 734-483-9363
  • Fax: 734-483-9557
Mailing address:
  • Phone: 734-483-9363
  • Fax: 734-483-9557

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

VIII. Authorized Official

Name: KETA J COWAN
Title or Position: EXECUTIVE DIRECTOR
Credential: JD
Phone: 734-483-9363