Basic Information
| Provider Information | |||||||||
| NPI: | 1346330313 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAUREL HEALTH CARE COMPANY OF PERRINTON | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | THE LAURELS OF FULTON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4735 RANGER RD | ||||||||
| Address2: | RFD #1 | ||||||||
| City: | PERRINTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892365433 | ||||||||
| FaxNumber: | 9892367672 | ||||||||
| Practice Location | |||||||||
| Address1: | 4735 RANGER RD | ||||||||
| Address2: | RFD #1 | ||||||||
| City: | PERRINTON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 48871 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9892365433 | ||||||||
| FaxNumber: | 9892367672 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/13/2006 | ||||||||
| LastUpdateDate: | 10/05/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATTON | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6147948800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | 294010 | MI | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
| ID | Type | State | Issuer | Description | 294010 | 01 | MI | NH LICENSE # | OTHER | 3202046 | 05 | MI | MEDICAID | 7105581 | 01 | MI | UNITED HEALTH CARE ID # | OTHER |