Provider Demographics
NPI:1801854815
Name:ST. JUDE NURSING CENTER, INC.
Entity Type:Organization
Organization Name:ST. JUDE NURSING CENTER, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:BRADLEY
Authorized Official - Middle Name:JM
Authorized Official - Last Name:MALI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:734-261-4800
Mailing Address - Street 1:34350 ANN ARBOR TRL
Mailing Address - Street 2:
Mailing Address - City:LIVONIA
Mailing Address - State:MI
Mailing Address - Zip Code:48150-3606
Mailing Address - Country:US
Mailing Address - Phone:734-261-4800
Mailing Address - Fax:734-261-0430
Practice Address - Street 1:34350 ANN ARBOR TRL
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48150-3606
Practice Address - Country:US
Practice Address - Phone:734-261-4800
Practice Address - Fax:734-261-0430
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-02
Last Update Date:2012-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI824260314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4797426Medicaid
MI09568OtherBCBS OF MI
MI824260Medicaid
MI824260Medicaid
MI4797426Medicaid