MEDICARE: OAKWOOD YOUTH PROGRAMS, 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	208100000X	Physical Medicine & Rehabilitation Physician	4301061207	MI

General Provider Information

NPI Number	:	1790959120
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	OAKWOOD YOUTH PROGRAMS, LLC

Provider Business Mailing Address
First Line	:	26901 BEAUMONT BLVD
Second Line	:	COMPLIANCE
City	:	SOUTHFIELD
State	:	MI
Zip	:	48033-3849
Country	:	US
Telephone Number	:	947-522-1964
Fax Number	:

Provider Business Practice Location Address
First Line	:	18501 ROTUNDA DR
Second Line	:	STE 200
City	:	DEARBORN
State	:	MI
Zip	:	48124-3891
Country	:	US
Telephone Number	:	313-996-1960
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT SHARED SERVICES
Name	:	LEE ANN ODOM
Credential	:
Telephone Number	:	947-522-3326

Provider Enumeration Date	:	04/16/2008
Last Update Date	:	10/21/2021

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