Provider Demographics
NPI:1700865169
Name:ST JOHN SENIOR COMMUNITY
Entity Type:Organization
Organization Name:ST JOHN SENIOR COMMUNITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:TOMASINE
Authorized Official - Middle Name:F
Authorized Official - Last Name:MARX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-753-0310
Mailing Address - Street 1:28000 DEQUINDRE
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092
Mailing Address - Country:US
Mailing Address - Phone:586-753-0310
Mailing Address - Fax:
Practice Address - Street 1:18300 E WARREN
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224
Practice Address - Country:US
Practice Address - Phone:313-343-8000
Practice Address - Fax:313-343-8959
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-13
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIBHS834032314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
09900OtherBCBS
235476Medicare ID - Type Unspecified