Basic Information
| Provider Information | |||||||||
| NPI: | 1922088780 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | HENRY FORD CONTINUING CARE CORP | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | HENRY FORD CONTINUING CARE CORPORATION - ROSEVILLE | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 19850 HARPER AVENUE | ||||||||
| Address2: | |||||||||
| City: | HARPER WOODS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482251804 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3136403375 | ||||||||
| FaxNumber: | 3138226789 | ||||||||
| Practice Location | |||||||||
| Address1: | 25375 KELLY ROAD | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480664960 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867736022 | ||||||||
| FaxNumber: | 5867712424 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/18/2006 | ||||||||
| LastUpdateDate: | 08/07/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KOCHANSKI | ||||||||
| AuthorizedOfficialFirstName: | ANN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | DIRECTOR OF OPERATIONS | ||||||||
| AuthorizedOfficialTelephone: | 5867736022 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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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 | 2637693 | 05 | MI | MEDICAID |