Healthcare Provider Details

I. General information

NPI: 1497364442
Provider Name (Legal Business Name): BOLTON BROOK MANOR
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/27/2020
Last Update Date: 07/27/2020
Certification Date: 07/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4554 THOMAS RD
METAMORA MI
48455-9220
US

IV. Provider business mailing address

4554 THOMAS RD
METAMORA MI
48455-9220
US

V. Phone/Fax

Practice location:
  • Phone: 810-678-2087
  • Fax: 810-678-2766
Mailing address:
  • Phone: 810-678-2087
  • Fax: 810-678-2766

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. SUNIL R BHATTAD
Title or Position: ADMINISTRATOR
Credential:
Phone: 248-797-8519