Basic Information
| Provider Information | |||||||||
| NPI: | 1730546250 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | EAST LANSING OPCO, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | MEDILODGE OF CAMPUS AREA | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 NEW LA GRANGE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402224870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298062 | ||||||||
| FaxNumber: | 5024290650 | ||||||||
| Practice Location | |||||||||
| Address1: | 2815 NORTHWIND DR | ||||||||
| Address2: | |||||||||
| City: | EAST LANSING | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488235003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5173320817 | ||||||||
| FaxNumber: | 5173361221 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/28/2016 | ||||||||
| LastUpdateDate: | 01/28/2016 | ||||||||
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| AuthorizedOfficialLastName: | ROGERS | ||||||||
| AuthorizedOfficialFirstName: | STACEY | ||||||||
| AuthorizedOfficialMiddleName: | PAUL | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5024298062 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.