Provider Demographics
NPI:1679218739
Name:MACOMB OAKLAND REGIONAL CENTER INC.
Entity Type:Organization
Organization Name:MACOMB OAKLAND REGIONAL CENTER INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:AMBER
Authorized Official - Middle Name:
Authorized Official - Last Name:BRANTLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-263-8720
Mailing Address - Street 1:19805 FARMINGTON RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1444
Mailing Address - Country:US
Mailing Address - Phone:248-536-5085
Mailing Address - Fax:248-536-5086
Practice Address - Street 1:5111 AUTO CLUB DR
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48126-2749
Practice Address - Country:US
Practice Address - Phone:248-536-5085
Practice Address - Fax:248-536-5086
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-03
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1023199965Medicaid