Healthcare Provider Details

I. General information

NPI: 1558033175
Provider Name (Legal Business Name): WARREN MI OPCO LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2021
Last Update Date: 10/05/2021
Certification Date: 10/05/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12250 E 12 MILE RD
WARREN MI
48093-3516
US

IV. Provider business mailing address

362 E KENNEDY BLVD
LAKEWOOD NJ
08701-1434
US

V. Phone/Fax

Practice location:
  • Phone: 718-838-1501
  • 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: ROB KORN
Title or Position: MANAGER
Credential:
Phone: 718-838-1501