Healthcare Provider Details

I. General information

NPI: 1932118718
Provider Name (Legal Business Name): CHURCH OF CHRIST HOME FOR THE AGED
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23575 15 MILE RD
CLINTON TOWNSHIP MI
48035-3108
US

IV. Provider business mailing address

23575 15 MILE RD
CLINTON TOWNSHIP MI
48035-3108
US

V. Phone/Fax

Practice location:
  • Phone: 586-791-2470
  • Fax: 586-791-2475
Mailing address:
  • Phone: 586-791-2470
  • Fax: 586-791-2475

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number50-422
License Number StateMI

VIII. Authorized Official

Name: MR. GERALD L BERGER
Title or Position: DIRECTOR OF FINANCE
Credential:
Phone: 586-791-2470