MEDICARE: FOUNTAIN BLEU NURSING & REHABILITATION CENTER INC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1083864722
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	FOUNTAIN BLEU NURSING & REHABILITATION CENTER INC

Provider Business Mailing Address
First Line	:	25440 5 MILE RD
Second Line	:
City	:	REDFORD
State	:	MI
Zip	:	48239-3881
Country	:	US
Telephone Number	:	313-255-2273
Fax Number	:	313-255-2425

Provider Business Practice Location Address
First Line	:	19175 ANGLIN ST
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48234-1407
Country	:	US
Telephone Number	:	313-892-3600
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MR. CHARLES A DUNN
Credential	:
Telephone Number	:	313-255-2273

Provider Enumeration Date	:	09/30/2008
Last Update Date	:	09/30/2008

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