| Independent Lifestyle Clubhouse Llc | |
|
4427 Inkster Rd Inkster MI 48141-3058 | |
| (313) 622-3287 | |
| Not Available |
| Full Name | Independent Lifestyle Clubhouse Llc |
|---|---|
| Speciality | Clinic/Center |
| Location | 4427 Inkster Rd, Inkster, Michigan |
| Authorized Official Name and Position | Shondra Lynn Jackson (DIRECTOR) |
| Authorized Official Contact | 3136223287 |
| Accepts Medicare Insurance | Yes. This clinic participates in medicare program and accept medicare insurance. |
| Mailing Address | Practice Location Address |
|---|---|
| Independent Lifestyle Clubhouse Llc 29723 Steinhauer St Inkster MI 48141-3419 Ph: (313) 622-3287 | Independent Lifestyle Clubhouse Llc 4427 Inkster Rd Inkster MI 48141-3058 Ph: (313) 622-3287 |
| NPI Number | 1235685694 |
|---|---|
| Provider Enumeration Date | 08/26/2016 |
| Last Update Date | 02/05/2019 |
| Medicare PECOS PAC ID | 0042558413 |
|---|---|
| Medicare Enrollment ID | O20190208002758 |
| Identifier | Type | State | Issuer |
|---|---|---|---|
| 1235685694 | NPI | - | NPPES |
| Taxonomy | Type | License (State) | Status |
|---|---|---|---|
| 261QM0850X | Clinic/center - Adult Mental Health | (* (Not Available)) | Primary |
| Provider Name | Florine Bond |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1770505075 PECOS PAC ID: 8123021177 Enrollment ID: I20060814000244 |
| Provider Name | Kelly K Manson |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1306037551 PECOS PAC ID: 2668697764 Enrollment ID: I20140703001030 |
| Provider Name | Serena E Eagan |
|---|---|
| Provider Type | Practitioner - Clinical Social Worker |
| Provider Identifiers | NPI Number: 1982841052 PECOS PAC ID: 6406103852 Enrollment ID: I20180717002603 |
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