Provider Demographics
NPI:1356599922
Name:THERAMATRIX, INC.
Entity type:Organization
Organization Name:THERAMATRIX, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-333-3335
Mailing Address - Street 1:900 AUBURN AVE
Mailing Address - Street 2:
Mailing Address - City:PONTIAC
Mailing Address - State:MI
Mailing Address - Zip Code:48342-3300
Mailing Address - Country:US
Mailing Address - Phone:248-333-3335
Mailing Address - Fax:248-333-0276
Practice Address - Street 1:23411 GRATIOT
Practice Address - Street 2:
Practice Address - City:EASTPOINTE
Practice Address - State:MI
Practice Address - Zip Code:48021-1644
Practice Address - Country:US
Practice Address - Phone:586-776-0080
Practice Address - Fax:786-776-4349
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:THERAMATRIX, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-09-08
Last Update Date:2016-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI261Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4682141Medicaid
MI236558Medicare Oscar/Certification