Provider Demographics
NPI:1174041321
Name:MICHIGAN INSTITUTE OF PERFORMANCE AND HEALTH
Entity Type:Organization
Organization Name:MICHIGAN INSTITUTE OF PERFORMANCE AND HEALTH
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/CLINIC DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MARK
Authorized Official - Middle Name:S
Authorized Official - Last Name:WELLS
Authorized Official - Suffix:
Authorized Official - Credentials:LMSW
Authorized Official - Phone:248-404-7151
Mailing Address - Street 1:43902 WOODWARD AVE STE 230
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48302-5022
Mailing Address - Country:US
Mailing Address - Phone:248-481-8428
Mailing Address - Fax:248-977-5462
Practice Address - Street 1:43902 WOODWARD AVE STE 230
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD HILLS
Practice Address - State:MI
Practice Address - Zip Code:48302-5022
Practice Address - Country:US
Practice Address - Phone:248-481-8428
Practice Address - Fax:248-977-5462
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-07
Last Update Date:2024-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No251S00000XAgenciesCommunity/Behavioral Health
No261QC1500XAmbulatory Health Care FacilitiesClinic/CenterCommunity Health
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
No261QM0855XAmbulatory Health Care FacilitiesClinic/CenterAdolescent and Children Mental Health
No261QM1100XAmbulatory Health Care FacilitiesClinic/CenterMilitary/U.S. Coast Guard Outpatient
No324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
No3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children
No253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIVC0005376Medicaid