=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275355273
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | FOUNDATIONS DETROIT,LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2024
-----------------------------------------------------
Last Update Date | 10/30/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2172 E PARIS AVE SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-6106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-684-4025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2172 E PARIS AVE SE
-----------------------------------------------------
City | GRAND RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49546-6106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-684-4025
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | VICE PRESIDENT
-----------------------------------------------------
Name | STEVE FILTON
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 610-768-3482
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QR0405X
-----------------------------------------------------
Taxonomy Name | Substance Use Disorder Rehabilitation Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------