Provider Demographics
NPI:1255442190
Name:LIFE- ALYSIS KIDNEY CENTER, LLC
Entity type:Organization
Organization Name:LIFE- ALYSIS KIDNEY CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:LYLE
Authorized Official - Middle Name:MARUICE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-371-5433
Mailing Address - Street 1:5830 CONNER ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48213-3458
Mailing Address - Country:US
Mailing Address - Phone:313-371-5433
Mailing Address - Fax:313-371-6937
Practice Address - Street 1:5830 CONNER ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48213-3458
Practice Address - Country:US
Practice Address - Phone:313-371-5433
Practice Address - Fax:313-371-6937
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-31
Last Update Date:2013-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI302R00000X302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4603219Medicaid
MI232616Medicare Oscar/Certification