Provider Demographics
NPI:1366912669
Name:STATE OF MICHIGAN
Entity type:Organization
Organization Name:STATE OF MICHIGAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:
Authorized Official - Last Name:ENGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-226-3576
Mailing Address - Street 1:425 FISHER ST
Mailing Address - Street 2:
Mailing Address - City:MARQUETTE
Mailing Address - State:MI
Mailing Address - Zip Code:49855-4521
Mailing Address - Country:US
Mailing Address - Phone:906-226-3576
Mailing Address - Fax:906-226-2380
Practice Address - Street 1:425 FISHER ST
Practice Address - Street 2:
Practice Address - City:MARQUETTE
Practice Address - State:MI
Practice Address - Zip Code:49855-4521
Practice Address - Country:US
Practice Address - Phone:906-226-3576
Practice Address - Fax:906-226-2380
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:STATE OF MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2018-11-29
Last Update Date:2018-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility