MEDICARE: LIGHT OF RECOVERY INC

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	320800000X	Mental Illness Community Based Residential Treatment Facility	6801015887	MI

General Provider Information

NPI Number	:	1891988937
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIGHT OF RECOVERY INC

Provider Business Mailing Address
First Line	:	2008 W GRAND BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48208-1021
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2008 W GRAND BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48208-1021
Country	:	US
Telephone Number	:	313-898-5938
Fax Number	:

Authorized Official
Title or Position	:	SOCIAL WORKER
Name	:	SERVILLA HARRIS
Credential	:
Telephone Number	:	313-898-5938

Provider Enumeration Date	:	08/22/2007
Last Update Date	:	07/02/2013

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Directions to “LIGHT OF RECOVERY INC ” Practice Location

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