Provider Demographics
NPI:1801282637
Name:TIMELESS TREASURE VILLAGE
Entity type:Organization
Organization Name:TIMELESS TREASURE VILLAGE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE
Authorized Official - Prefix:
Authorized Official - First Name:LOUIS
Authorized Official - Middle Name:CORNELUIS
Authorized Official - Last Name:BROOKS
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:313-768-4048
Mailing Address - Street 1:23636 MICHIGAN AVE # 488
Mailing Address - Street 2:
Mailing Address - City:DEARBORN
Mailing Address - State:MI
Mailing Address - Zip Code:48124-1910
Mailing Address - Country:US
Mailing Address - Phone:313-523-7807
Mailing Address - Fax:
Practice Address - Street 1:23636 MICHIGAN AVE # 488
Practice Address - Street 2:
Practice Address - City:DEARBORN
Practice Address - State:MI
Practice Address - Zip Code:48124-1910
Practice Address - Country:US
Practice Address - Phone:313-768-4084
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-04-08
Last Update Date:2015-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization