Provider Demographics
NPI:1720071707
Name:NEW LIGHT BAPTIST CHURCH NURSING HOME, INC.
Entity Type:Organization
Organization Name:NEW LIGHT BAPTIST CHURCH NURSING HOME, INC.
Other - Org Name:NEW LIGHT NURSING HOME, INC.
Other - Org Type:Other Name
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:GEORGE
Authorized Official - Middle Name:B
Authorized Official - Last Name:TALLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-491-7920
Mailing Address - Street 1:9500 GRAND RIVER AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48204-2132
Mailing Address - Country:US
Mailing Address - Phone:313-491-7920
Mailing Address - Fax:313-491-0510
Practice Address - Street 1:9500 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2132
Practice Address - Country:US
Practice Address - Phone:313-491-7920
Practice Address - Fax:313-491-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI2152057314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2152057Medicaid
23-5234Medicare ID - Type Unspecified