Provider Demographics
NPI:1134125131
Name:LAKE ORION NURSING CENTER CORPORATION
Entity Type:Organization
Organization Name:LAKE ORION NURSING CENTER CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:MATT
Authorized Official - Middle Name:
Authorized Official - Last Name:LEGAULT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-338-5691
Mailing Address - Street 1:585 E FLINT ST
Mailing Address - Street 2:
Mailing Address - City:LAKE ORION
Mailing Address - State:MI
Mailing Address - Zip Code:48362-3209
Mailing Address - Country:US
Mailing Address - Phone:248-693-0505
Mailing Address - Fax:248-693-6071
Practice Address - Street 1:585 E FLINT ST
Practice Address - Street 2:
Practice Address - City:LAKE ORION
Practice Address - State:MI
Practice Address - Zip Code:48362-3209
Practice Address - Country:US
Practice Address - Phone:248-693-0505
Practice Address - Fax:248-693-6071
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:POH MEDICAL CENTER
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-06-23
Last Update Date:2016-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI634024314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2616817Medicaid
MI2616817Medicaid