Provider Demographics
NPI:1497006100
Name:RESIDENTIAL WELLNESS GROUP LLC
Entity Type:Organization
Organization Name:RESIDENTIAL WELLNESS GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:CHANNON
Authorized Official - Middle Name:
Authorized Official - Last Name:SYKES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-829-4925
Mailing Address - Street 1:14236 KENTUCKY ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-2363
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:16179 MEYERS RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48235-4108
Practice Address - Country:US
Practice Address - Phone:800-318-6141
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-21
Last Update Date:2012-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care