MEDICARE: LUTHERAN HOMES OF MICHIGAN INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	310400000X	Assisted Living Facility		MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	O 9665	OTHER	MI	BCBS INS. PROVIDER #

General Provider Information

NPI Number	:	1639173214
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LUTHERAN HOMES OF MICHIGAN INC

Provider Business Mailing Address
First Line	:	9710 JUNCTION RD
Second Line	:	PO BOX 329
City	:	FRANKENMUTH
State	:	MI
Zip	:	48734-0329
Country	:	US
Telephone Number	:	989-652-3470
Fax Number	:	989-652-3480

Provider Business Practice Location Address
First Line	:	1236 S MONROE STREET
Second Line	:	HOME FOR THE AGED
City	:	MONROE
State	:	MI
Zip	:	48161-3998
Country	:	US
Telephone Number	:	734-241-9533
Fax Number	:	734-241-9108

Authorized Official
Title or Position	:	CONTROLLER
Name	:	MR. MICHAEL G CORBY
Credential	:
Telephone Number	:	989-652-3470

Provider Enumeration Date	:	06/10/2005
Last Update Date	:	09/14/2007

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