Provider Demographics
NPI:1154848224
Name:GAYLORD OPCO, LLC
Entity Type:Organization
Organization Name:GAYLORD OPCO, LLC
Other - Org Name:MEDILODGE OF GAYLORD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:STACEY
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:ROGERS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-429-8062
Mailing Address - Street 1:7400 NEW LA GRANGE RD STE 100
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40222-4870
Mailing Address - Country:US
Mailing Address - Phone:502-429-8062
Mailing Address - Fax:
Practice Address - Street 1:508 RANDOM LN
Practice Address - Street 2:
Practice Address - City:GAYLORD
Practice Address - State:MI
Practice Address - Zip Code:49735-9304
Practice Address - Country:US
Practice Address - Phone:989-732-3508
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-08-29
Last Update Date:2017-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility