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General NPI Number Information
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NPI Number | 1235685694
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Entity Type | Organization
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Legal Business Name | INDEPENDENT LIFESTYLE CLUBHOUSE LLC
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Dates
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Enumeration Date | 08/26/2016
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Last Update Date | 02/05/2019
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Provider Practice Location Address
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Address Line | 4427 INKSTER RD
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City | INKSTER
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State | MI
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Zip | 48141-3058
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Country | US
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Telephone | 313-622-3287
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Fax |
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Provider Business Mailing Address
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Address Line | 29723 STEINHAUER ST
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City | INKSTER
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State | MI
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Zip | 48141-3419
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Country | US
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Telephone | 313-622-3287
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Fax |
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Authorized Official
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Title or Position | DIRECTOR
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Name | MRS. SHONDRA LYNN JACKSON
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Credential |
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Telephone | 313-622-3287
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM0850X
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Taxonomy Name | Adult Mental Health Clinic/Center
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License Number |
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License Number State |
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