1225029465 NPI number — DETROIT NURSING CENTER, LLC

Table of content: (NPI 1225029465)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1225029465 NPI number — DETROIT NURSING CENTER, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DETROIT NURSING CENTER, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
IMPERIAL HEALTH CARE CENTRE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1225029465
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/18/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3701 W LUNT AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LINCOLNWOOD
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60712-2615
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
847-440-2660
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
26505 POWERS AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
DEARBORN HEIGHTS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48125-1327
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
313-291-6200
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/04/2005

Additional Information

Authorized Official

Authorized Official Last Name:
WEISS
Authorized Official First Name:
LEONARD
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO/MANAGER
Authorized Official Telephone Number:
847-674-7600

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  82-4012 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 60/4618249 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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