Provider Demographics
NPI:1790952232
Name:SANBORN GRATIOT MEMORIAL HOME
Entity Type:Organization
Organization Name:SANBORN GRATIOT MEMORIAL HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:SWANTEK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-388-1200
Mailing Address - Street 1:2732 CHERRY ST
Mailing Address - Street 2:
Mailing Address - City:PORT HURON
Mailing Address - State:MI
Mailing Address - Zip Code:48060-2916
Mailing Address - Country:US
Mailing Address - Phone:810-985-5631
Mailing Address - Fax:810-985-1560
Practice Address - Street 1:2732 CHERRY ST
Practice Address - Street 2:
Practice Address - City:PORT HURON
Practice Address - State:MI
Practice Address - Zip Code:48060-2916
Practice Address - Country:US
Practice Address - Phone:810-985-5631
Practice Address - Fax:810-985-1560
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-14
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAH740236889310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility