Provider Demographics
NPI:1285802652
Name:TRILOGY HEALTHCARE OF JACKSON, LLC
Entity type:Organization
Organization Name:TRILOGY HEALTHCARE OF JACKSON, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:SVP - FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:PAUL
Authorized Official - Middle Name:
Authorized Official - Last Name:PLEVYAK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:502-213-1710
Mailing Address - Street 1:703 ROBINSON ROAD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-2538
Mailing Address - Country:US
Mailing Address - Phone:517-787-5140
Mailing Address - Fax:517-787-0722
Practice Address - Street 1:703 ROBINSON ROAD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-2538
Practice Address - Country:US
Practice Address - Phone:517-787-5140
Practice Address - Fax:517-787-0722
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:TRILOGY HEALTH SERVICES, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2008-02-19
Last Update Date:2011-10-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5286170Medicaid
MI5286170Medicaid