Organization
INDEPENDENT LIFESTYLE CLUBHOUSE LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MRS. SHONDRA LYNN JACKSON (DIRECTOR)
(313) 622-3287
Entity
Organization
Contact information
Practice address
4427 INKSTER RD, INKSTER, MI 48141-3058
(313) 622-3287
Mailing address
29723 STEINHAUER ST, INKSTER, MI 48141-3419
(313) 622-3287
Taxonomy
Speciality
Code
Description
License number
State
261QM0850X
Adult Mental Health Clinic/Center
Primary
—
—
Other
Enumeration date
08/26/2016
Last updated
02/05/2019
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