Provider Demographics
NPI:1831511393
Name:LIFESTYLES SUPPORTIVE LIVING SERVICES, LLC
Entity type:Organization
Organization Name:LIFESTYLES SUPPORTIVE LIVING SERVICES, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MANUEL
Authorized Official - Middle Name:DEWITT
Authorized Official - Last Name:THOMAS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:734-726-4086
Mailing Address - Street 1:2370 E STADIUM BLVD # 640
Mailing Address - Street 2:
Mailing Address - City:ANN ARBOR
Mailing Address - State:MI
Mailing Address - Zip Code:48104-4811
Mailing Address - Country:US
Mailing Address - Phone:734-726-4086
Mailing Address - Fax:
Practice Address - Street 1:2370 E STADIUM BLVD # 640
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48104-4811
Practice Address - Country:US
Practice Address - Phone:734-726-4086
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-01-16
Last Update Date:2017-04-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251B00000X, 347C00000X, 3747A0650X, 253Z00000X
MI320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No251B00000XAgenciesCase Management
No347C00000XTransportation ServicesPrivate VehicleGroup - Multi-Specialty
No3747A0650XNursing Service Related ProvidersTechnicianAttendant Care ProviderGroup - Multi-Specialty
No320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental IllnessGroup - Multi-Specialty