Provider Demographics
NPI:1184602088
Name:EAST GRAND NURSING HOME, INC.
Entity type:Organization
Organization Name:EAST GRAND NURSING HOME, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SECRETARY/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:L
Authorized Official - Last Name:BARTON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-824-8224
Mailing Address - Street 1:130 E GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48207-3799
Mailing Address - Country:US
Mailing Address - Phone:313-824-8224
Mailing Address - Fax:313-824-8220
Practice Address - Street 1:130 E GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3799
Practice Address - Country:US
Practice Address - Phone:313-824-8224
Practice Address - Fax:313-824-8220
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-03
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI834330313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI60Medicaid
MI2155219Medicaid
MI23E075OtherPROVIDER/SUPPLIER/CLIA ID
MI834330OtherMDCIS/BHS LICENSE NUMBER