Provider Demographics
NPI:1225633035
Name:PACKARD SPECIALIZED RESIDENTIAL
Entity Type:Organization
Organization Name:PACKARD SPECIALIZED RESIDENTIAL
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:MITCHELL
Authorized Official - Middle Name:F
Authorized Official - Last Name:NAEGELE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-288-2226
Mailing Address - Street 1:1173 S PACKARD AVE
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48509-2311
Mailing Address - Country:US
Mailing Address - Phone:810-288-2226
Mailing Address - Fax:
Practice Address - Street 1:1173 S PACKARD AVE
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48509-2311
Practice Address - Country:US
Practice Address - Phone:810-288-2226
Practice Address - Fax:810-462-1093
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-12-01
Last Update Date:2020-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility