Basic Information
| Provider Information | |||||||||
| NPI: | 1326013731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEDILODGE OF MONROE, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 481 VILLAGE GREEN LN | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481623367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342426282 | ||||||||
| FaxNumber: | 7342426491 | ||||||||
| Practice Location | |||||||||
| Address1: | 481 VILLAGE GREEN LN | ||||||||
| Address2: | |||||||||
| City: | MONROE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481623367 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7342426282 | ||||||||
| FaxNumber: | 7342426491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | DALY | ||||||||
| AuthorizedOfficialFirstName: | JANET | ||||||||
| AuthorizedOfficialMiddleName: | E | ||||||||
| AuthorizedOfficialTitleorPosition: | NURSING HOME ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 7342426282 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MS. | ||||||||
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| AuthorizedOfficialCredential: | RN,NHA | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 584040 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4216270 | 05 | MI | MEDICAID |