Healthcare Provider Details

I. General information

NPI: 1376545533
Provider Name (Legal Business Name): MICHIGAN MASONIC HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2005
Last Update Date: 12/29/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1200 WRIGHT AVE
ALMA MI
48801-1133
US

IV. Provider business mailing address

1200 WRIGHT AVE
ALMA MI
48801-1133
US

V. Phone/Fax

Practice location:
  • Phone: 989-463-3141
  • Fax: 989-466-2796
Mailing address:
  • Phone: 989-463-3141
  • Fax: 989-466-2796

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number294040
License Number StateMI

VIII. Authorized Official

Name: GREGORY MAPES
Title or Position: PRESIDENT
Credential: PRESIDENT, HOME BOAR
Phone: 989-463-4285