Healthcare Provider Details

I. General information

NPI: 1073573655
Provider Name (Legal Business Name): MEDILODGE OF BLOOMFIELD
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

50 W SQUARE LAKE RD
BLOOMFIELD HILLS MI
48302-0461
US

IV. Provider business mailing address

64500 VAN DYKE RD
WASHINGTON MI
48095-2583
US

V. Phone/Fax

Practice location:
  • Phone: 248-338-0345
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number634050
License Number StateMI

VIII. Authorized Official

Name: JAN KUEPPERS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 586-752-5008