Provider Demographics
NPI:1497168215
Name:BLUE LIGHT INC.
Entity Type:Organization
Organization Name:BLUE LIGHT INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:PHYLLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-999-4890
Mailing Address - Street 1:26105 ORCHARD LAKE RD
Mailing Address - Street 2:SUITE #208
Mailing Address - City:FARMINGTON HILLS
Mailing Address - State:MI
Mailing Address - Zip Code:48334-4576
Mailing Address - Country:US
Mailing Address - Phone:248-615-3042
Mailing Address - Fax:248-615-3047
Practice Address - Street 1:26105 ORCHARD LAKE RD
Practice Address - Street 2:SUITE #208
Practice Address - City:FARMINGTON HILLS
Practice Address - State:MI
Practice Address - Zip Code:48334-4576
Practice Address - Country:US
Practice Address - Phone:248-615-3042
Practice Address - Fax:248-615-3047
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-06-09
Last Update Date:2014-06-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1693530Medicaid