Basic Information
Provider Information | |||||||||
NPI: | 1972559193 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | LAUREL HEALTH CARE COMPANY OF BATTLE CREEK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | THE LAURELS OF BEDFORD | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 4000 TOWN CTR STE 2000 | ||||||||
Address2: |   | ||||||||
City: | SOUTHFIELD | ||||||||
State: | MI | ||||||||
PostalCode: | 480751415 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2483860300 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 270 NORTH BEDFORD ROAD | ||||||||
Address2: |   | ||||||||
City: | BATTLE CREEK | ||||||||
State: | MI | ||||||||
PostalCode: | 49017 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6169682296 | ||||||||
FaxNumber: | 6169688943 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/26/2006 | ||||||||
LastUpdateDate: | 09/08/2021 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KHAN | ||||||||
AuthorizedOfficialFirstName: | ANIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CFO | ||||||||
AuthorizedOfficialTelephone: | 2483860300 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MR. | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 09/08/2021 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 313M00000X | 134150 | MI | N |   | Nursing & Custodial Care Facilities | Nursing Facility/Intermediate Care Facility |   | 314000000X | 134150 | MI | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 134150 | 01 | MI | NURSING HOME LICENSE # | OTHER | 09668 | 01 | MI | BLUE CROSS CLUE SHIELD # | OTHER | 3198257 | 05 | MI |   | MEDICAID |