Organization
WYOMING OPCO, LLC
Active
Other names
Medilodge of Wyoming
Organization subpart
No
Provider details
NPI number
Authorized official
MR. STACEY PAUL ROGERS (CHIEF FINANCIAL OFFICER)
(502) 429-8062
Entity
Organization
Contact information
Practice address
2786 56TH ST SW, WYOMING, MI 49418-8708
(616) 261-3960
(616) 261-3925
Mailing address
7400 NEW LA GRANGE RD, SUITE 100, LOUISVILLE, KY 40222-4870
(502) 429-8062
(502) 429-0650
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
—
—
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1831596907
—
MI
Enumeration date
12/04/2014
Last updated
07/17/2015
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