# MEDILODGE OF ROYAL OAK

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1396705992
- **Authorized official:** JAN KUEPPERS (CHIEF FINANCIAL OFFICER)
- **Authorized official phone:** (586) 752-5008

## Contact information

- **Practice address:** 3030 GREENFIELD RD, ROYAL OAK, MI 48073-6528
- **Practice address phone:** (248) 288-6610
- **Mailing address:** 64500 VAN DYKE RD, WASHINGTON, MI 48095-2583

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 634360 | MI | Yes |

## Other

- **Enumeration date:** 03/27/2006
- **Last updated:** 08/22/2020

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 09982 | BLUE CROSS OF MICHIGAN | MI |
| 05 | — | 2695973 | — | MI |