Basic Information
| Provider Information | |||||||||
| NPI: | 1558949602 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | THE LAURELS OF KETTERING, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE LAURELS OF KETTERING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 4000 TOWN CTR STE 2000 | ||||||||
| Address2: | |||||||||
| City: | SOUTHFIELD | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480751415 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2483860300 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 694 ISAAC PRUGH WAY | ||||||||
| Address2: | |||||||||
| City: | KETTERING | ||||||||
| State: | OH | ||||||||
| PostalCode: | 454293481 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5133195371 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2021 | ||||||||
| LastUpdateDate: | 08/13/2021 | ||||||||
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| AuthorizedOfficialLastName: | QAZI | ||||||||
| AuthorizedOfficialFirstName: | MOHAMMAD | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT/CEO | ||||||||
| AuthorizedOfficialTelephone: | 2483860300 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 08/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 0448098 | 05 | OH | MEDICAID |