Basic Information
| Provider Information | |||||||||
| NPI: | 1720278997 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | 11941 BELSAY ROAD OPERATING COMPANY, LLC | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | GRAND BLANC REHABILITATION AND NURSING CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11941 BELSAY RD | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484391702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106941970 | ||||||||
| FaxNumber: | 8106944081 | ||||||||
| Practice Location | |||||||||
| Address1: | 11941 BELSAY RD | ||||||||
| Address2: | |||||||||
| City: | GRAND BLANC | ||||||||
| State: | MI | ||||||||
| PostalCode: | 484391702 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8106941970 | ||||||||
| FaxNumber: | 8106944081 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/25/2007 | ||||||||
| LastUpdateDate: | 07/30/2007 | ||||||||
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| AuthorizedOfficialLastName: | BRESLIN | ||||||||
| AuthorizedOfficialFirstName: | KEVIN | ||||||||
| AuthorizedOfficialMiddleName: | P | ||||||||
| AuthorizedOfficialTitleorPosition: | EVP | ||||||||
| AuthorizedOfficialTelephone: | 2012424004 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 332B00000X | 4962065 | MI | Y | Suppliers | Durable Medical Equipment & Medical Supplies |
ID Information
| ID | Type | State | Issuer | Description | 4962065 | 05 | MI | MEDICAID |