Basic Information
| Provider Information | |||||||||
| NPI: | 1508953787 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IHS ACQUISITION NO. 111, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CLARKSTON SPECIALTY HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 930 RIDGEBROOK RD | ||||||||
| Address2: | |||||||||
| City: | SPARKS | ||||||||
| State: | MD | ||||||||
| PostalCode: | 211529390 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107731000 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4800 CLINTONVILLE RD | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486740903 | ||||||||
| FaxNumber: | 2486743431 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2006 | ||||||||
| LastUpdateDate: | 12/20/2007 | ||||||||
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| AuthorizedOfficialLastName: | CANNY | ||||||||
| AuthorizedOfficialFirstName: | MAGGIE | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2486740903 | ||||||||
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| 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 | 4163588 | 05 | MI | MEDICAID |