MEDICARE: THE BERRY CENTER, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	261QA1903X	Ambulatory Surgical Clinic/Center	636818	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	636818	OTHER	MI	STATE LICENSE NUMBER

General Provider Information

NPI Number	:	1316994122
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	THE BERRY CENTER, LLC

Provider Business Mailing Address
First Line	:	28500 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-2936
Country	:	US
Telephone Number	:	248-851-6767
Fax Number	:	248-851-2077

Provider Business Practice Location Address
First Line	:	28500 ORCHARD LAKE RD
Second Line	:
City	:	FARMINGTON HILLS
State	:	MI
Zip	:	48334-2936
Country	:	US
Telephone Number	:	248-851-6767
Fax Number	:	248-851-2977

Authorized Official
Title or Position	:	BOARD MANAGER
Name	:	MR. WILLIAM L CARPENTER JR.
Credential	:
Telephone Number	:	317-621-7475

Provider Enumeration Date	:	05/27/2006
Last Update Date	:	12/14/2007

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