Provider Demographics
NPI:1225115637
Name:ELMWOOD GERIATRIC VILLAGE, INC
Entity Type:Organization
Organization Name:ELMWOOD GERIATRIC VILLAGE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:DONALD
Authorized Official - Middle Name:JAMES
Authorized Official - Last Name:BORTZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-759-5966
Mailing Address - Street 1:11700 E 10 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48089-3903
Mailing Address - Country:US
Mailing Address - Phone:586-759-5966
Mailing Address - Fax:586-759-8006
Practice Address - Street 1:1881 E GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48211-3041
Practice Address - Country:US
Practice Address - Phone:313-922-1600
Practice Address - Fax:313-922-4756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-11-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI834980314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235454Medicare ID - Type Unspecified