Basic Information
| Provider Information | |||||||||
| NPI: | 1407855695 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | PRESBYTERIAN VILLAGE REDFORD | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE VILLAGE OF REDFORD | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 25330 W 6 MILE RD | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482402105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135316874 | ||||||||
| FaxNumber: | 3135416491 | ||||||||
| Practice Location | |||||||||
| Address1: | 25330 W 6 MILE RD | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482402105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3135316874 | ||||||||
| FaxNumber: | 3135416491 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/19/2005 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | COLEMAN | ||||||||
| AuthorizedOfficialFirstName: | ROSE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 3135416418 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | RN, NHA | ||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 824250 | MI | X | Nursing & Custodial Care Facilities | Skilled Nursing Facility | 310400000X | MI | X | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | 824250 | 01 | MI | STATE FACILITY NUMBER | OTHER |