Provider Demographics
NPI:1376545533
Name:MICHIGAN MASONIC HOME
Entity Type:Organization
Organization Name:MICHIGAN MASONIC HOME
Other - Org Name:MASONIC PATHWAYS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GREGORY
Authorized Official - Middle Name:
Authorized Official - Last Name:MAPES
Authorized Official - Suffix:
Authorized Official - Credentials:PRESIDENT, HOME BOAR
Authorized Official - Phone:989-463-4285
Mailing Address - Street 1:1200 WRIGHT AVE
Mailing Address - Street 2:
Mailing Address - City:ALMA
Mailing Address - State:MI
Mailing Address - Zip Code:48801-1133
Mailing Address - Country:US
Mailing Address - Phone:989-463-3141
Mailing Address - Fax:989-466-2796
Practice Address - Street 1:1200 WRIGHT AVE
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1133
Practice Address - Country:US
Practice Address - Phone:989-463-3141
Practice Address - Fax:989-466-2796
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-01
Last Update Date:2014-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI294040314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2080833Medicaid
MI09597OtherBCBS OF MICHIGAN
235020Medicare Oscar/Certification