Basic Information
| Provider Information | |||||||||
| NPI: | 1578205910 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 9400 CONANT ST MI OPCO LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 150 OBERLIN AVE N STE 6 | ||||||||
| Address2: | |||||||||
| City: | LAKEWOOD | ||||||||
| State: | NJ | ||||||||
| PostalCode: | 087014535 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 9400 CONANT ST | ||||||||
| Address2: | |||||||||
| City: | HAMTRAMCK | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482123538 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138744500 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/07/2022 | ||||||||
| LastUpdateDate: | 04/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | JEIDEL | ||||||||
| AuthorizedOfficialFirstName: | JACOB | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRINCIPAL | ||||||||
| AuthorizedOfficialTelephone: | 9177505089 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.