=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669386603
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SOUL4REAL
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/29/2026
-----------------------------------------------------
Last Update Date | 09/29/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29673 NORTHWESTERN HWY
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48034-1033
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-629-0050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 286 ALHAMBRA ST
-----------------------------------------------------
City | PONTIAC
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48341-1090
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-575-6229
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | TINA L PHILLIPS
-----------------------------------------------------
Credential | OWNER
-----------------------------------------------------
Telephone | 313-575-6229
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 132700000X
-----------------------------------------------------
Taxonomy Name | Dietary Manager
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | NULL
-----------------------------------------------------