Healthcare Provider Details

I. General information

NPI: 1356661714
Provider Name (Legal Business Name): SALEM STREET MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2010
Last Update Date: 06/08/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18474 SALEM ST
DETROIT MI
48219-3055
US

IV. Provider business mailing address

18474 SALEM ST
DETROIT MI
48219-3055
US

V. Phone/Fax

Practice location:
  • Phone: 313-505-6525
  • Fax:
Mailing address:
  • Phone: 313-505-6525
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAS820288716
License Number StateMI

VIII. Authorized Official

Name: MS. NICOLE S GUYTON
Title or Position: OWNER
Credential:
Phone: 313-505-6525