=====================================================
General NPI Number Information
=====================================================
NPI Number | 1649677873
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRIA HEALTHCARE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/03/2014
-----------------------------------------------------
Last Update Date | 12/03/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 7893 HARDING ST
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48180-2535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-316-0923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7893 HARDING ST
-----------------------------------------------------
City | TAYLOR
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48180-2535
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-316-0923
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | COTA/L
-----------------------------------------------------
Name | MRS. MARIANNE DENISE RODEN
-----------------------------------------------------
Credential | COTA/L
-----------------------------------------------------
Telephone | 313-316-0923
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 5202001741
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 251C00000X
-----------------------------------------------------
Taxonomy Name | Developmentally Disabled Services Day Training Agency
-----------------------------------------------------
License Number | 5202001741
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------