Basic Information
| Provider Information | |||||||||
| NPI: | 1407516305 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | NORTHVILLE MANOR LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 30700 TELEGRAPH RD STE 2504 | ||||||||
| Address2: | |||||||||
| City: | BINGHAM FARMS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480254571 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2485931990 | ||||||||
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| Practice Location | |||||||||
| Address1: | 520 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | NORTHVILLE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481671529 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483494290 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/20/2021 | ||||||||
| LastUpdateDate: | 12/20/2021 | ||||||||
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| AuthorizedOfficialLastName: | UDDIN | ||||||||
| AuthorizedOfficialFirstName: | FAHIM | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2485931990 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 12/20/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.