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General NPI Number Information
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NPI Number | 1255442190
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Entity Type | Organization
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Legal Business Name | LIFE- ALYSIS KIDNEY CENTER, LLC
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 01/23/2013
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Provider Practice Location Address
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Address Line | 5830 CONNER ST
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City | DETROIT
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State | MI
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Zip | 48213-3458
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Country | US
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Telephone | 313-371-5433
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Fax | 313-371-6937
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Provider Business Mailing Address
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Address Line | 5830 CONNER ST
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City | DETROIT
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State | MI
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Zip | 48213-3458
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Country | US
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Telephone | 313-371-5433
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Fax | 313-371-6937
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Authorized Official
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Title or Position | PARTNER
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Name | MR. LYLE MARUICE GRAY
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Credential |
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Telephone | 313-371-5433
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 302R00000X
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Taxonomy Name | Health Maintenance Organization
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License Number | 302R00000X
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License Number State | MI
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