Provider Demographics
NPI:1225108418
Name:HOLLY CONVALESCENT CENTER, INC.
Entity Type:Organization
Organization Name:HOLLY CONVALESCENT CENTER, INC.
Other - Org Name:HOLLY CONVALESCENT CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:AUTHORIZED OFFICIAL
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:HANEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-634-9281
Mailing Address - Street 1:313 SHERWOOD ST
Mailing Address - Street 2:
Mailing Address - City:HOLLY
Mailing Address - State:MI
Mailing Address - Zip Code:48442-1232
Mailing Address - Country:US
Mailing Address - Phone:248-634-9281
Mailing Address - Fax:248-634-9553
Practice Address - Street 1:313 SHERWOOD ST
Practice Address - Street 2:
Practice Address - City:HOLLY
Practice Address - State:MI
Practice Address - Zip Code:48442-1232
Practice Address - Country:US
Practice Address - Phone:248-634-9281
Practice Address - Fax:248-634-9553
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-08
Last Update Date:2015-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI63-4380313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI63-4380OtherSTATE FACILITY NUMBER
MI23E252Medicaid