Healthcare Provider Details

I. General information

NPI: 1700037082
Provider Name (Legal Business Name): BERTRAM'S MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1202 CHURCH ST
FLINT MI
48502-1015
US

IV. Provider business mailing address

1202 CHURCH ST
FLINT MI
48502-1015
US

V. Phone/Fax

Practice location:
  • Phone: 810-238-1430
  • Fax: 810-238-1447
Mailing address:
  • Phone: 810-238-1430
  • Fax: 810-238-1447

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License NumberAM250289405
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberAM250289405
License Number StateMI

VIII. Authorized Official

Name: NICHOLAS D BURNETT
Title or Position: OWNER/ADMINISTRATOR
Credential:
Phone: 810-238-1430