Healthcare Provider Details

I. General information

NPI: 1134348311
Provider Name (Legal Business Name): COURTYARD MANOR OF WIXOM
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/25/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48578 PONTIAC TRL
WIXOM MI
48393-2554
US

IV. Provider business mailing address

3275 MARTIN RD SUITE 127
COMMERCE TOWNSHIP MI
48390-1642
US

V. Phone/Fax

Practice location:
  • Phone: 248-669-5263
  • Fax: 248-669-5035
Mailing address:
  • Phone: 248-926-2920
  • Fax: 248-926-2933

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. RONALD M. PARADOWICZ
Title or Position: VICE PRESIDENT
Credential:
Phone: 248-926-2920