MEDICARE: CAMPBELLS PERSONAL CARE HOME #4, 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	310400000X	Assisted Living Facility	AL630015496	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	AL630015496	OTHER	MI	STATE OF MICHIGAN DEPARTMENT OF HUMAN SERVICES

General Provider Information

NPI Number	:	1588994065
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CAMPBELLS PERSONAL CARE HOME #4, INC.

Provider Business Mailing Address
First Line	:	PO BOX 821
Second Line	:
City	:	LAPEER
State	:	MI
Zip	:	48446-0821
Country	:	US
Telephone Number	:	810-245-9400
Fax Number	:

Provider Business Practice Location Address
First Line	:	1900 LAKEVILLE RD
Second Line	:
City	:	LEONARD
State	:	MI
Zip	:	48367-3306
Country	:	US
Telephone Number	:	248-628-6348
Fax Number	:

Authorized Official
Title or Position	:	OPERATIONS MANAGHER
Name	:	DEBORAH S. VAUBEL
Credential	:
Telephone Number	:	810-245-9400

Provider Enumeration Date	:	01/06/2010
Last Update Date	:	01/06/2010

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