Healthcare Provider Details

I. General information

NPI: 1003887662
Provider Name (Legal Business Name): MEDILODGE OF PLYMOUTH, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/31/2006
Last Update Date: 07/16/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

395 W ANN ARBOR TRL
PLYMOUTH MI
48170-1641
US

IV. Provider business mailing address

395 W ANN ARBOR TRL
PLYMOUTH MI
48170-1641
US

V. Phone/Fax

Practice location:
  • Phone: 734-453-3983
  • Fax: 734-414-8231
Mailing address:
  • Phone: 734-453-3983
  • Fax: 734-414-8231

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number824320
License Number StateMI

VIII. Authorized Official

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