Provider Demographics
NPI:1053636175
Name:STONEGATE VILLAGE ASSISTED LIVING
Entity Type:Organization
Organization Name:STONEGATE VILLAGE ASSISTED LIVING
Other - Org Name:STONEGATE VILLAGE ASSISTED LIVING - LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NOBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-648-9410
Mailing Address - Street 1:70 W ARGYLE ST
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:MI
Mailing Address - Zip Code:48471-1081
Mailing Address - Country:US
Mailing Address - Phone:810-648-9410
Mailing Address - Fax:
Practice Address - Street 1:70 W ARGYLE ST
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:MI
Practice Address - Zip Code:48471-1081
Practice Address - Country:US
Practice Address - Phone:810-648-9410
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-31
Last Update Date:2011-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D1102197291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory