Provider Demographics
NPI:1649677873
Name:CENTRIA HEALTHCARE
Entity type:Organization
Organization Name:CENTRIA HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COTA/L
Authorized Official - Prefix:MRS
Authorized Official - First Name:MARIANNE
Authorized Official - Middle Name:DENISE
Authorized Official - Last Name:RODEN
Authorized Official - Suffix:
Authorized Official - Credentials:COTA/L
Authorized Official - Phone:313-316-0923
Mailing Address - Street 1:7893 HARDING ST
Mailing Address - Street 2:
Mailing Address - City:TAYLOR
Mailing Address - State:MI
Mailing Address - Zip Code:48180-2535
Mailing Address - Country:US
Mailing Address - Phone:313-316-0923
Mailing Address - Fax:
Practice Address - Street 1:7893 HARDING ST
Practice Address - Street 2:
Practice Address - City:TAYLOR
Practice Address - State:MI
Practice Address - Zip Code:48180-2535
Practice Address - Country:US
Practice Address - Phone:313-316-0923
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-12-03
Last Update Date:2014-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5202001741261Q00000X, 251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5202001741OtherALL OTHER INSURANCE COMPANY
MI5202001741Medicaid
MI5202001741OtherALL OTHER INSURANCE COMPANY
MI5202001741Medicare NSC
MI5202001741Medicare PIN
MI5202001741Medicare UPIN