Provider Demographics
NPI:1407013709
Name:EASTER SEALS - MICHIGAN, INC.
Entity Type:Organization
Organization Name:EASTER SEALS - MICHIGAN, INC.
Other - Org Name:FAMILY SERVICES SOUTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:WIRTH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-475-6400
Mailing Address - Street 1:2387 E WALTON BLVD
Mailing Address - Street 2:
Mailing Address - City:AUBURN HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48326-1955
Mailing Address - Country:US
Mailing Address - Phone:248-475-6400
Mailing Address - Fax:248-475-6402
Practice Address - Street 1:24445 NORTHWESTERN HWY STE 100
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2436
Practice Address - Country:US
Practice Address - Phone:248-483-7804
Practice Address - Fax:248-483-7868
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:EASTER SEALS - MICHIGAN, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-05-22
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N26360Medicare PIN