Provider Demographics
NPI:1942522818
Name:PERSONALIZED NURSING LIGHT HOUSE, INC.
Entity Type:Organization
Organization Name:PERSONALIZED NURSING LIGHT HOUSE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PALIWODA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CAC-M, CCS-M
Authorized Official - Phone:734-451-7800
Mailing Address - Street 1:575 S MAIN ST
Mailing Address - Street 2:SUITE 6
Mailing Address - City:PLYMOUTH
Mailing Address - State:MI
Mailing Address - Zip Code:48170-1778
Mailing Address - Country:US
Mailing Address - Phone:734-451-7800
Mailing Address - Fax:734-451-5410
Practice Address - Street 1:7430 NORTH INKSTER ROAD
Practice Address - Street 2:
Practice Address - City:DEARBORN HEIGHTS
Practice Address - State:MI
Practice Address - Zip Code:48127
Practice Address - Country:US
Practice Address - Phone:313-274-7879
Practice Address - Fax:313-274-7933
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-19
Last Update Date:2014-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI823088324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility