- Enrollment id
- O20150106001631
- Enrollment state
- MI
- Provider type code
- 00-18
- Provider type text
- PART A PROVIDER - SKILLED NURSING FACILITY
- Npi
- 1790180255
- Multiple npi flag
- N
- Ccn
- 235226
- Associate id
- 9436472073
- Organization name
- GRAND BLANC OPCO, LLC
- Doing business as name
- MEDILODGE OF GRAND BLANC
- Incorporation date
- 2014-05-09
- Incorporation state
- DE
- Organization type structure
- LLC
- Proprietary nonprofit
- P
- Nursing home provider name
- MEDILODGE OF GRAND BLANC
- Affiliation entity name
- MEDILODGE
- Affiliation entity id
- 345
- Address line 1
- 11941 BELSAY RD
- City
- GRAND BLANC
- State
- MI
- Zip code
- 484391702