Healthcare Provider Details

I. General information

NPI: 1427045442
Provider Name (Legal Business Name): MEDILODGE OF ST. CLAIR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/04/2005
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4220 HOSPITAL DR
EAST CHINA MI
48054-2200
US

IV. Provider business mailing address

4220 HOSPITAL DR
EAST CHINA MI
48054-2200
US

V. Phone/Fax

Practice location:
  • Phone: 810-329-4736
  • Fax: 810-329-6282
Mailing address:
  • Phone: 810-329-4736
  • Fax: 810-329-6282

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number744040
License Number StateMI

VIII. Authorized Official

Name: JANA STUEVER
Title or Position: ADMINISTRATOR
Credential:
Phone: 810-329-4736