Basic Information
| Provider Information | |||||||||
| NPI: | 1447347794 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | LAUREL HEALTH CARE COMPANY OF WAYLAND | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE LAURELS OF SANDY CREEK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 425 E ELM ST | ||||||||
| Address2: | |||||||||
| City: | WAYLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493481109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167922249 | ||||||||
| FaxNumber: | 6167926121 | ||||||||
| Practice Location | |||||||||
| Address1: | 425 E ELM ST | ||||||||
| Address2: | |||||||||
| City: | WAYLAND | ||||||||
| State: | MI | ||||||||
| PostalCode: | 493481109 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6167922249 | ||||||||
| FaxNumber: | 6167926121 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2006 | ||||||||
| LastUpdateDate: | 09/05/2007 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PATTON | ||||||||
| AuthorizedOfficialFirstName: | TIMOTHY | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6147948800 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332BP3500X | 0340303 | MI | Y | Suppliers | Durable Medical Equipment & Medical Supplies | Parenteral & Enteral Nutrition |
ID Information
| ID | Type | State | Issuer | Description | 7105598 | 01 | MI | UNITED HEALTH CARE ID # | OTHER | 034030 | 01 | SC | NH LICENSE # | OTHER | 3202091 | 05 | MI | MEDICAID |