Provider Demographics
NPI:1932118718
Name:CHURCH OF CHRIST HOME FOR THE AGED
Entity Type:Organization
Organization Name:CHURCH OF CHRIST HOME FOR THE AGED
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:L
Authorized Official - Last Name:BERGER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-791-2470
Mailing Address - Street 1:23575 15 MILE RD
Mailing Address - Street 2:
Mailing Address - City:CLINTON TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48035-3108
Mailing Address - Country:US
Mailing Address - Phone:586-791-2470
Mailing Address - Fax:586-791-2475
Practice Address - Street 1:23575 15 MILE RD
Practice Address - Street 2:
Practice Address - City:CLINTON TOWNSHIP
Practice Address - State:MI
Practice Address - Zip Code:48035-3108
Practice Address - Country:US
Practice Address - Phone:586-791-2470
Practice Address - Fax:586-791-2475
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-07
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI50-422314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2153528Medicaid
MI235619Medicare Oscar/Certification