Provider Demographics
NPI:1124061353
Name:SSC FENTON OPERATING COMPANY LLC
Entity type:Organization
Organization Name:SSC FENTON OPERATING COMPANY LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTOR AR
Authorized Official - Prefix:
Authorized Official - First Name:KELLE
Authorized Official - Middle Name:C
Authorized Official - Last Name:SANTORO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-467-5728
Mailing Address - Street 1:5300 W SAM HOUSTON PKWY N
Mailing Address - Street 2:SUITE 100
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77041-5161
Mailing Address - Country:US
Mailing Address - Phone:832-467-6000
Mailing Address - Fax:
Practice Address - Street 1:111 TREALOUT DR
Practice Address - Street 2:
Practice Address - City:FENTON
Practice Address - State:MI
Practice Address - Zip Code:48430-1481
Practice Address - Country:US
Practice Address - Phone:810-629-4105
Practice Address - Fax:810-629-7538
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-14
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI254210314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4882204Medicaid
MI235348Medicare Oscar/Certification