1457346801 NPI number — ROUBAL'S NURSING HOME, INC.

Table of content: (NPI 1457346801)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457346801 NPI number — ROUBAL'S NURSING HOME, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ROUBAL'S NURSING HOME, INC.
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:
Provider Other Organization Name Type Code:
6
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:
1457346801
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/08/2023
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
N306 MAPLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
STEPHENSON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49887-8910
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-753-4981
Provider Business Mailing Address Fax Number:
906-753-4680

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N306 MAPLE ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
STEPHENSON
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49887-8910
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-753-4981
Provider Business Practice Location Address Fax Number:
906-753-4680
Provider Enumeration Date:
09/13/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FRIEDMAN
Authorized Official First Name:
BENJAMIN
Authorized Official Middle Name:
T
Authorized Official Title or Position:
SHAREHOLDER
Authorized Official Telephone Number:
847-881-6025

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  554020 , 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: 1508658 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com