=====================================================
General NPI Number Information
=====================================================
NPI Number | 1639157993
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVANGELICAL HOMES OF MICHIGAN
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/06/2006
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14900 SHORELINE DR
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48313-2251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-247-4700
-----------------------------------------------------
Fax | 586-247-1499
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14900 SHORELINE DR
-----------------------------------------------------
City | STERLING HEIGHTS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48313-2251
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-247-4700
-----------------------------------------------------
Fax | 586-247-1499
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | MR. LAWRENCE G PETROSKEY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 313-836-3499
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 504015
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------