Healthcare Provider Details

I. General information

NPI: 1275713463
Provider Name (Legal Business Name): THE MEDILODGE GROUP, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 05/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

64500 VAN DYKE RD
WASHINGTON MI
48095-2583
US

IV. Provider business mailing address

64500 VAN DYKE RD
WASHINGTON MI
48095-2583
US

V. Phone/Fax

Practice location:
  • Phone: 586-752-5008
  • Fax: 586-752-7609
Mailing address:
  • Phone: 586-752-5008
  • Fax: 586-752-7609

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