Provider Demographics
NPI:1235685694
Name:INDEPENDENT LIFESTYLE CLUBHOUSE LLC
Entity Type:Organization
Organization Name:INDEPENDENT LIFESTYLE CLUBHOUSE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHONDRA
Authorized Official - Middle Name:LYNN
Authorized Official - Last Name:JACKSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-622-3287
Mailing Address - Street 1:29723 STEINHAUER ST
Mailing Address - Street 2:
Mailing Address - City:INKSTER
Mailing Address - State:MI
Mailing Address - Zip Code:48141-3419
Mailing Address - Country:US
Mailing Address - Phone:313-622-3287
Mailing Address - Fax:
Practice Address - Street 1:4427 INKSTER RD
Practice Address - Street 2:
Practice Address - City:INKSTER
Practice Address - State:MI
Practice Address - Zip Code:48141-3058
Practice Address - Country:US
Practice Address - Phone:313-622-3287
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-08-26
Last Update Date:2019-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health