Basic Information
| Provider Information | |||||||||
| NPI: | 1114972734 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAUREL HEALTH CARE COMPANY OF GALESBURG | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | THE LAURELS OF GALESBURG | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 4000 TOWN CTR STE 2000 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480751415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483860300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1080 N 35TH ST | ||||||||
| Address2: | |||||||||
| City: | GALESBURG | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490539727 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6166657043 | ||||||||
| FaxNumber: | 6166654080 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/23/2006 | ||||||||
| LastUpdateDate: | 09/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KHAN | ||||||||
| AuthorizedOfficialFirstName: | ANIS | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 2483860300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 09/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 394150 | MI | N | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility | 314000000X | 394150 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 3319728 | 05 | MI | MEDICAID | 394150 | 01 | MI | NURSING HOME LICENSE # | OTHER | 09796 | 01 | MI | BLUE CROSS BLUE SHIELD # | OTHER |