Healthcare Provider Details

I. General information

NPI: 1891955720
Provider Name (Legal Business Name): MEDILODGE OF PORT HURON, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/13/2008
Last Update Date: 06/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5635 LAKESHORE RD
FORT GRATIOT MI
48059-2817
US

IV. Provider business mailing address

5635 LAKESHORE RD
FORT GRATIOT MI
48059-2817
US

V. Phone/Fax

Practice location:
  • Phone: 810-385-7447
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: KATHLEEN DENEAN
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 586-752-5008