Provider Demographics
NPI:1629316815
Name:LIFE SKILLS VILLAGE, PLLC
Entity Type:Organization
Organization Name:LIFE SKILLS VILLAGE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MR
Authorized Official - First Name:NATE
Authorized Official - Middle Name:
Authorized Official - Last Name:GARDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-788-4300
Mailing Address - Street 1:20010 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1408
Mailing Address - Country:US
Mailing Address - Phone:248-788-4300
Mailing Address - Fax:248-605-8099
Practice Address - Street 1:25900 GREENFIELD RD
Practice Address - Street 2:SUITE 100
Practice Address - City:OAK PARK
Practice Address - State:MI
Practice Address - Zip Code:48237-1292
Practice Address - Country:US
Practice Address - Phone:248-788-4300
Practice Address - Fax:248-605-8099
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-22
Last Update Date:2020-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MID31065251S00000X
261QM1300X, 261QR0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
No261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation