Basic Information
| Provider Information | |||||||||
| NPI: | 1548699036 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CLARKSTON OPERATING COMPANY LLC | ||||||||
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| OtherOrganizationName: | CLARKSTON SPECIALTY HEALTHCARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4800 CLINTONVILLE RD | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486740903 | ||||||||
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| Practice Location | |||||||||
| Address1: | 4800 CLINTONVILLE RD | ||||||||
| Address2: | |||||||||
| City: | CLARKSTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483464297 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2486740903 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2013 | ||||||||
| LastUpdateDate: | 11/11/2020 | ||||||||
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| AuthorizedOfficialLastName: | SANTORO | ||||||||
| AuthorizedOfficialFirstName: | KELLE | ||||||||
| AuthorizedOfficialMiddleName: | C | ||||||||
| AuthorizedOfficialTitleorPosition: | SR DIRECTOR AR | ||||||||
| AuthorizedOfficialTelephone: | 8324675728 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 11/11/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.