Provider Demographics
NPI:1639201262
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:S
Authorized Official - Last Name:PALIWODA
Authorized Official - Suffix:
Authorized Official - Credentials:MBA, CAC-I
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 1:575 S MAIN ST STE 6
Practice Address - Street 2:
Practice Address - City:PLYMOUTH
Practice Address - State:MI
Practice Address - Zip Code:48170-1778
Practice Address - Country:US
Practice Address - Phone:734-451-7800
Practice Address - Fax:734-451-5410
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-09
Last Update Date:2018-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI821032261QR0405X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0405XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Substance Use Disorder
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI821032OtherSTATE LICENSE