Provider Demographics
NPI:1861088155
Name:LIFE BRIDGE HEALTH SERVICES LLC
Entity type:Organization
Organization Name:LIFE BRIDGE HEALTH SERVICES LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:DANIELLE
Authorized Official - Middle Name:NICOLE
Authorized Official - Last Name:MCDANIEL
Authorized Official - Suffix:
Authorized Official - Credentials:JD
Authorized Official - Phone:248-971-9005
Mailing Address - Street 1:PO BOX 867
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48037-0867
Mailing Address - Country:US
Mailing Address - Phone:248-971-9005
Mailing Address - Fax:734-212-5084
Practice Address - Street 1:24001 SOUTHFIELD RD STE 103
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-2800
Practice Address - Country:US
Practice Address - Phone:586-991-1602
Practice Address - Fax:734-212-5084
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-21
Last Update Date:2020-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care