Healthcare Provider Details

I. General information

NPI: 1114974391
Provider Name (Legal Business Name): FENTON HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2006
Last Update Date: 01/15/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

512 BEACH ST
FENTON MI
48430-3122
US

IV. Provider business mailing address

512 BEACH ST
FENTON MI
48430-3122
US

V. Phone/Fax

Practice location:
  • Phone: 810-629-4117
  • Fax: 810-629-0491
Mailing address:
  • Phone: 810-629-4117
  • Fax: 810-629-0491

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number254050
License Number StateMI

VIII. Authorized Official

Name: LARRY D. WHITE
Title or Position: MANAGER
Credential:
Phone: 810-629-4117