Healthcare Provider Details

I. General information

NPI: 1154848224
Provider Name (Legal Business Name): GAYLORD OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/29/2017
Last Update Date: 08/29/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

508 RANDOM LN
GAYLORD MI
49735-9304
US

IV. Provider business mailing address

7400 NEW LA GRANGE RD STE 100
LOUISVILLE KY
40222-4870
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-3508
  • Fax:
Mailing address:
  • Phone: 502-429-8062
  • 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: MR. STACEY PAUL ROGERS
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 502-429-8062