Provider Demographics
NPI:1669932109
Name:INNER MAN WELLNESS AND SUPPORT SERVICES
Entity type:Organization
Organization Name:INNER MAN WELLNESS AND SUPPORT SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RODERICK
Authorized Official - Middle Name:
Authorized Official - Last Name:GILLISON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-802-2712
Mailing Address - Street 1:4890 BALLANTRAE RD
Mailing Address - Street 2:
Mailing Address - City:BLOOMFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48301-1000
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4890 BALLANTRAE RD
Practice Address - Street 2:
Practice Address - City:BLOOMFIELD
Practice Address - State:MI
Practice Address - Zip Code:48301-1000
Practice Address - Country:US
Practice Address - Phone:248-802-2712
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-03-21
Last Update Date:2019-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility