Basic Information
| Provider Information | |||||||||
| NPI: | 1083864722 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FOUNTAIN BLEU NURSING & REHABILITATION CENTER INC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 25440 5 MILE RD | ||||||||
| Address2: | |||||||||
| City: | REDFORD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482393881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3132552273 | ||||||||
| FaxNumber: | 3132552425 | ||||||||
| Practice Location | |||||||||
| Address1: | 19175 ANGLIN ST | ||||||||
| Address2: | |||||||||
| City: | DETROIT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 482341407 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3138923600 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 09/30/2008 | ||||||||
| LastUpdateDate: | 09/30/2008 | ||||||||
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| AuthorizedOfficialLastName: | DUNN | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 3132552273 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.