Basic Information
| Provider Information | |||||||||
| NPI: | 1780266718 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SACRED HEART REHABILITATION CENTER, INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 400 STODDARD RD | ||||||||
| Address2: | |||||||||
| City: | RICHMOND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480622505 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103922167 | ||||||||
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| Practice Location | |||||||||
| Address1: | 248 FERRY LN | ||||||||
| Address2: | |||||||||
| City: | SAINT IGNACE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497811828 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103922167 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/28/2021 | ||||||||
| LastUpdateDate: | 04/28/2021 | ||||||||
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| AuthorizedOfficialLastName: | ARDOIN | ||||||||
| AuthorizedOfficialFirstName: | PAM | ||||||||
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| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 8103922167 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 04/28/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251S00000X | Y | Agencies | Community/Behavioral Health |
ID Information
| ID | Type | State | Issuer | Description | 0490025 | 05 | MI | MEDICAID |