Provider Demographics
NPI:1164753828
Name:IS-CARE CLS, INC.
Entity Type:Organization
Organization Name:IS-CARE CLS, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FOUNDER & DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:GWYNEVERE
Authorized Official - Middle Name:M
Authorized Official - Last Name:COLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-706-7237
Mailing Address - Street 1:16524 ROSEMONT
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48219
Mailing Address - Country:US
Mailing Address - Phone:313-706-7237
Mailing Address - Fax:
Practice Address - Street 1:1777 N RADEMACHER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48209-2049
Practice Address - Country:US
Practice Address - Phone:313-894-1630
Practice Address - Fax:313-894-1648
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-01-20
Last Update Date:2015-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI054700Medicare PIN