Provider Demographics
NPI:1528015625
Name:TROUSDALE FOUNDATION OF MICHIGAN, INC
Entity Type:Organization
Organization Name:TROUSDALE FOUNDATION OF MICHIGAN, INC
Other - Org Name:MARION MANOR NURSING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:D
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:423-478-5953
Mailing Address - Street 1:485 CENTRAL AVE NE
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:TN
Mailing Address - Zip Code:37311-5541
Mailing Address - Country:US
Mailing Address - Phone:423-478-5953
Mailing Address - Fax:423-479-0476
Practice Address - Street 1:18591 QUARRY ST
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:MI
Practice Address - Zip Code:48193-4522
Practice Address - Country:US
Practice Address - Phone:734-282-2100
Practice Address - Fax:734-282-2136
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-27
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI824210314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235376Medicare ID - Type UnspecifiedMEDICARE