Basic Information
| Provider Information | |||||||||
| NPI: | 1235648528 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MICHIGAN CITY RCF LP | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | SILVER BIRCH OF MICHIGAN CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 401 N FRANKLIN ST STE 4 SOUTH | ||||||||
| Address2: | |||||||||
| City: | CHICAGO | ||||||||
| State: | IL | ||||||||
| PostalCode: | 606544673 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3122393534 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 4400 E MICHIGAN BLVD | ||||||||
| Address2: | |||||||||
| City: | MICHIGAN CITY | ||||||||
| State: | IN | ||||||||
| PostalCode: | 463603153 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2198796115 | ||||||||
| FaxNumber: | 2198795618 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/29/2017 | ||||||||
| LastUpdateDate: | 09/29/2017 | ||||||||
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| AuthorizedOfficialLastName: | COCAGNE | ||||||||
| AuthorizedOfficialFirstName: | DAVID | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER OF GENERAL PARTNER | ||||||||
| AuthorizedOfficialTelephone: | 3122393534 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
No ID Information.