Healthcare Provider Details

I. General information

NPI: 1700165834
Provider Name (Legal Business Name): GENESEE MANOR INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2011
Last Update Date: 08/07/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19415 PURLINGBROOK ST
LIVONIA MI
48152-1950
US

IV. Provider business mailing address

19158 SANTA ROSA DR
DETROIT MI
48221-1732
US

V. Phone/Fax

Practice location:
  • Phone: 313-449-6895
  • Fax: 313-345-6591
Mailing address:
  • Phone: 313-449-6895
  • Fax: 313-945-6591

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberAS820294980
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAS820294980
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberAS820294980
License Number StateMI
# 4
Primary TaxonomyN
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License NumberAS820294980
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAS820294980
License Number StateMI

VIII. Authorized Official

Name: GARY WESLEY RAY I
Title or Position: OWNER
Credential:
Phone: 313-449-6895