Basic Information
| Provider Information | |||||||||
| NPI: | 1437107042 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | RHEMA WLC OPERATING LLC | ||||||||
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| OtherOrganizationName: | MANOR OF WAYNE SKILLED NURSING AND REHABILITATION | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 17515 W NINE MILE RD | ||||||||
| Address2: | SUITE 925 | ||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48075 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485698400 | ||||||||
| FaxNumber: | 2485695070 | ||||||||
| Practice Location | |||||||||
| Address1: | 4429 VENOY RD | ||||||||
| Address2: | |||||||||
| City: | WAYNE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7343266424 | ||||||||
| FaxNumber: | 7344678160 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/05/2006 | ||||||||
| LastUpdateDate: | 08/27/2007 | ||||||||
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| AuthorizedOfficialLastName: | ROBINSON | ||||||||
| AuthorizedOfficialFirstName: | DERRICK | ||||||||
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| AuthorizedOfficialTitleorPosition: | VP OF FINANCE | ||||||||
| AuthorizedOfficialTelephone: | 2485698400 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 824460A | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4962047 | 05 | MI | MEDICAID |