Provider Demographics
NPI:1366633018
Name:SAMARITAS
Entity Type:Organization
Organization Name:SAMARITAS
Other - Org Name:SAMARITAS SENIOR LIVING CADILLAC
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:JENNY
Authorized Official - Middle Name:
Authorized Official - Last Name:CEDERSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-308-2764
Mailing Address - Street 1:8131 E JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48214-2610
Mailing Address - Country:US
Mailing Address - Phone:313-823-7700
Mailing Address - Fax:313-823-9604
Practice Address - Street 1:460 PEARL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2620
Practice Address - Country:US
Practice Address - Phone:231-775-0101
Practice Address - Fax:231-775-1390
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-08-07
Last Update Date:2019-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI844020314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5189936Medicaid
MI09537OtherBCBS
MI5189936Medicaid