Provider Demographics
NPI:1285110767
Name:PERSONALIZED NURSING LIGHT HOUSE INC
Entity type:Organization
Organization Name:PERSONALIZED NURSING LIGHT HOUSE INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:JOSEPH
Authorized Official - Middle Name:
Authorized Official - Last Name:PALIWODA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-231-3839
Mailing Address - Street 1:7752 N CANTON CENTER RD STE 120
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:MI
Mailing Address - Zip Code:48187-1328
Mailing Address - Country:US
Mailing Address - Phone:734-851-7311
Mailing Address - Fax:734-851-7312
Practice Address - Street 1:7752 N CANTON CENTER RD STE 120
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:MI
Practice Address - Zip Code:48187
Practice Address - Country:US
Practice Address - Phone:734-851-7311
Practice Address - Fax:734-851-7312
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-07-17
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MISA0821032324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI382942874OtherIRS