Provider Demographics
NPI:1760533699
Name:WAYNE COUNTY THERAPEUTIC, INC.
Entity Type:Organization
Organization Name:WAYNE COUNTY THERAPEUTIC, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MISS
Authorized Official - First Name:BERNICE
Authorized Official - Middle Name:ALBERTA
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:COTA
Authorized Official - Phone:248-354-6434
Mailing Address - Street 1:29510 7 MILE RD
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48152-1910
Mailing Address - Country:US
Mailing Address - Phone:248-427-9525
Mailing Address - Fax:248-427-9528
Practice Address - Street 1:29510 7 MILE RD
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1910
Practice Address - Country:US
Practice Address - Phone:248-427-9525
Practice Address - Fax:248-427-9528
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-16
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Not Answered207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
Not Answered363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0P01340Medicare ID - Type UnspecifiedPHYSICIAN SERVICES