Healthcare Provider Details

I. General information

NPI: 1720071707
Provider Name (Legal Business Name): NEW LIGHT BAPTIST CHURCH NURSING HOME, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/25/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9500 GRAND RIVER AVE
DETROIT MI
48204-2132
US

IV. Provider business mailing address

9500 GRAND RIVER AVE
DETROIT MI
48204-2132
US

V. Phone/Fax

Practice location:
  • Phone: 313-491-7920
  • Fax: 313-491-0510
Mailing address:
  • Phone: 313-491-7920
  • Fax: 313-491-0510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number2152057
License Number StateMI

VIII. Authorized Official

Name: MR. GEORGE B. TALLEY
Title or Position: ADMINISTRATOR
Credential:
Phone: 313-491-7920