Provider Demographics
NPI:1598160137
Name:MICHIGAN MASONIC HOME
Entity Type:Organization
Organization Name:MICHIGAN MASONIC HOME
Other - Org Name:WARWICK LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DON
Authorized Official - Middle Name:
Authorized Official - Last Name:PRAY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-466-3811
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 1:842 W WARWICK DR
Practice Address - Street 2:
Practice Address - City:ALMA
Practice Address - State:MI
Practice Address - Zip Code:48801-1178
Practice Address - Country:US
Practice Address - Phone:989-463-2200
Practice Address - Fax:989-463-2543
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:MICHIGAN MASONIC HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2014-10-24
Last Update Date:2014-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIL458405314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility