Provider Demographics
NPI:1245650035
Name:BANYAN SOBER LIVING OF MICHIGAN
Entity type:Organization
Organization Name:BANYAN SOBER LIVING OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:
Authorized Official - First Name:MACKENZIE
Authorized Official - Middle Name:
Authorized Official - Last Name:KOONCE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-233-8474
Mailing Address - Street 1:PO BOX 272
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-0272
Mailing Address - Country:US
Mailing Address - Phone:231-233-8474
Mailing Address - Fax:734-264-0732
Practice Address - Street 1:1023 WASHTENAW RD
Practice Address - Street 2:
Practice Address - City:YPSILANTI
Practice Address - State:MI
Practice Address - Zip Code:48197-2161
Practice Address - Country:US
Practice Address - Phone:231-233-8474
Practice Address - Fax:734-264-0732
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-04-21
Last Update Date:2014-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory