Healthcare Provider Details

I. General information

NPI: 1386742310
Provider Name (Legal Business Name): ODD FELLOW & REBEKAH HOME OF MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2388 W MICHIGAN AVE
JACKSON MI
49202-3919
US

IV. Provider business mailing address

2388 W MICHIGAN AVE
JACKSON MI
49202-3919
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-5140
  • Fax: 517-787-0722
Mailing address:
  • Phone:
  • Fax: 517-787-0722

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number384200
License Number StateMI

VIII. Authorized Official

Name: MR. JEREMY HILER
Title or Position: NURSING HOME ADMINISTRATOR
Credential: N.H.A.
Phone: 517-787-5140