Provider Demographics
NPI: | 1407087299 |
---|---|
Name: | CORPORATE MIND BODY SPA LLC |
Entity Type: | Organization |
Organization Name: | CORPORATE MIND BODY SPA LLC |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | PRESIDENT |
Authorized Official - Prefix: | MS |
Authorized Official - First Name: | LORESA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | ROBERTSON |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 313-806-0962 |
Mailing Address - Street 1: | 600 RENAISSANCE CTR # 1 |
Mailing Address - Street 2: | |
Mailing Address - City: | DETROIT |
Mailing Address - State: | MI |
Mailing Address - Zip Code: | 48243-1815 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 313-393-7995 |
Mailing Address - Fax: | 313-393-3208 |
Practice Address - Street 1: | 600 RENAISSANCE CTR # 1 |
Practice Address - Street 2: | |
Practice Address - City: | DETROIT |
Practice Address - State: | MI |
Practice Address - Zip Code: | 48243-1815 |
Practice Address - Country: | US |
Practice Address - Phone: | 313-393-7995 |
Practice Address - Fax: | 313-393-3208 |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2009-07-28 |
Last Update Date: | 2009-07-28 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
MI | 171W00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization | Group |
---|---|---|---|---|---|
Yes | 171W00000X | Other Service Providers | Contractor | Group - Single Specialty |