Provider Demographics
NPI:1720248644
Name:MEDILODGE OF MILFORD, LLC
Entity type:Organization
Organization Name:MEDILODGE OF MILFORD, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF EXECUTIVE OFFICIER
Authorized Official - Prefix:
Authorized Official - First Name:KATHLEEN
Authorized Official - Middle Name:
Authorized Official - Last Name:DENEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:586-752-5008
Mailing Address - Street 1:555 HIGHLAND AVE
Mailing Address - Street 2:
Mailing Address - City:MILFORD
Mailing Address - State:MI
Mailing Address - Zip Code:48381-1517
Mailing Address - Country:US
Mailing Address - Phone:586-752-5008
Mailing Address - Fax:586-752-7609
Practice Address - Street 1:555 HIGHLAND AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:MI
Practice Address - Zip Code:48381-1517
Practice Address - Country:US
Practice Address - Phone:248-685-1460
Practice Address - Fax:248-684-1564
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-06-13
Last Update Date:2013-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
235650Medicare Oscar/Certification