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General NPI Number Information
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NPI Number | 1629316815
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Entity Type | Organization
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Legal Business Name | LIFE SKILLS VILLAGE, PLLC
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Dates
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Enumeration Date | 01/22/2013
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Last Update Date | 02/12/2020
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Provider Practice Location Address
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Address Line | 25900 GREENFIELD RD SUITE 100
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City | OAK PARK
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State | MI
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Zip | 48237-1292
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Country | US
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Telephone | 248-788-4300
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Fax | 248-605-8099
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Provider Business Mailing Address
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Address Line | 20010 FARMINGTON RD
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City | LIVONIA
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State | MI
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Zip | 48152-1408
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Country | US
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Telephone | 248-788-4300
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Fax | 248-605-8099
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Authorized Official
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Title or Position | COO
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Name | MR. NATE GARDIN
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Credential |
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Telephone | 248-788-4300
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QM1300X
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Taxonomy Name | Multi-Specialty Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 261QR0400X
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Taxonomy Name | Rehabilitation Clinic/Center
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number | D31065
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License Number State | MI
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