Healthcare Provider Details

I. General information

NPI: 1699836346
Provider Name (Legal Business Name): STONE CREEK MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 08/01/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 STONE CREEK PASS
CLIO MI
48420
US

IV. Provider business mailing address

609 STONE CREEK PASS
CLIO MI
48420
US

V. Phone/Fax

Practice location:
  • Phone: 810-687-2855
  • Fax: 810-687-2855
Mailing address:
  • Phone: 810-687-2855
  • Fax: 810-687-2855

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License NumberAF250248959
License Number StateMI

VIII. Authorized Official

Name: MS. SHAWN MARIE THOMPSON
Title or Position: OWNER
Credential:
Phone: 810-687-2855