Provider Demographics
NPI:1760030183
Name:SPECIALLY MADE CO. LLC
Entity Type:Organization
Organization Name:SPECIALLY MADE CO. LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRES/CEO
Authorized Official - Prefix:
Authorized Official - First Name:KRISTIN
Authorized Official - Middle Name:
Authorized Official - Last Name:KILL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-790-4135
Mailing Address - Street 1:7631 N DIXBORO RD
Mailing Address - Street 2:
Mailing Address - City:SOUTH LYON
Mailing Address - State:MI
Mailing Address - Zip Code:48178-7008
Mailing Address - Country:US
Mailing Address - Phone:248-790-4135
Mailing Address - Fax:
Practice Address - Street 1:845 E SUMMERFIELD GLEN CIR
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-9161
Practice Address - Country:US
Practice Address - Phone:248-790-4135
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-28
Last Update Date:2019-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities