Provider Demographics
NPI:1134348311
Name:COURTYARD MANOR OF WIXOM
Entity type:Organization
Organization Name:COURTYARD MANOR OF WIXOM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:M
Authorized Official - Last Name:PARADOWICZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-926-2920
Mailing Address - Street 1:3275 MARTIN RD
Mailing Address - Street 2:SUITE 127
Mailing Address - City:COMMERCE TOWNSHIP
Mailing Address - State:MI
Mailing Address - Zip Code:48390-1642
Mailing Address - Country:US
Mailing Address - Phone:248-926-2920
Mailing Address - Fax:248-926-2933
Practice Address - Street 1:48578 PONTIAC TRL
Practice Address - Street 2:
Practice Address - City:WIXOM
Practice Address - State:MI
Practice Address - Zip Code:48393-2554
Practice Address - Country:US
Practice Address - Phone:248-669-5263
Practice Address - Fax:248-669-5035
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI3104A0625X, 3104A0625X, 3104A0625X, 3104A0625X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness