Basic Information
| Provider Information | |||||||||
| NPI: | 1134446677 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAGNUM HEALTH AND REHAB OF MONROE LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MAGNUM CARE OF MONROE | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1215 N TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481623368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342424848 | ||||||||
| FaxNumber: | 7342422007 | ||||||||
| Practice Location | |||||||||
| Address1: | 1215 N TELEGRAPH RD | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481623368 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342424848 | ||||||||
| FaxNumber: | 7342422007 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/23/2010 | ||||||||
| LastUpdateDate: | 01/27/2015 | ||||||||
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| AuthorizedOfficialLastName: | STODDARD | ||||||||
| AuthorizedOfficialFirstName: | SUSAN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7342424848 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 23-5232 | 01 | MI | MEDICARE | OTHER |