Healthcare Provider Details

I. General information

NPI: 1407516305
Provider Name (Legal Business Name): NORTHVILLE MANOR LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/20/2021
Last Update Date: 12/20/2021
Certification Date: 12/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 W MAIN ST
NORTHVILLE MI
48167-1529
US

IV. Provider business mailing address

30700 TELEGRAPH RD STE 2504
BINGHAM FARMS MI
48025-4571
US

V. Phone/Fax

Practice location:
  • Phone: 248-349-4290
  • Fax:
Mailing address:
  • Phone: 248-593-1990
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: FAHIM UDDIN
Title or Position: MEMBER
Credential:
Phone: 248-593-1990