Provider Demographics
NPI:1275802647
Name:LOVE KNOT MEDICAL CENTER,LLC
Entity Type:Organization
Organization Name:LOVE KNOT MEDICAL CENTER,LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KANISHA
Authorized Official - Middle Name:
Authorized Official - Last Name:BREWER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-627-1422
Mailing Address - Street 1:17234 GODDARD RD
Mailing Address - Street 2:
Mailing Address - City:ALLEN PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48101-4100
Mailing Address - Country:US
Mailing Address - Phone:313-627-1422
Mailing Address - Fax:
Practice Address - Street 1:17234 GODDARD RD
Practice Address - Street 2:
Practice Address - City:ALLEN PARK
Practice Address - State:MI
Practice Address - Zip Code:48101-4100
Practice Address - Country:US
Practice Address - Phone:313-627-1422
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-14
Last Update Date:2011-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service
No261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
No261QP3300XAmbulatory Health Care FacilitiesClinic/CenterPain
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation