Provider Demographics
NPI:1144469461
Name:LAKERIDGE VILLAGE, INC.
Entity type:Organization
Organization Name:LAKERIDGE VILLAGE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:EDDIE
Authorized Official - Middle Name:C
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:313-345-4310
Mailing Address - Street 1:15941 FAIRFIELD ST
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48238-4123
Mailing Address - Country:US
Mailing Address - Phone:313-345-4310
Mailing Address - Fax:313-345-4315
Practice Address - Street 1:15941 FAIRFIELD ST
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48238-4123
Practice Address - Country:US
Practice Address - Phone:313-345-4310
Practice Address - Fax:313-345-4315
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-02-10
Last Update Date:2020-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI822985324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility