Healthcare Provider Details

I. General information

NPI: 1013382225
Provider Name (Legal Business Name): LAKESIDE MANOR NURSING & REHABILITATION CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/14/2015
Last Update Date: 02/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13990 LAKESIDE CIR
STERLING HEIGHTS MI
48313-1318
US

IV. Provider business mailing address

30700 TELEGRAPH RD SUITE 2504
BINGHAM FARMS MI
48025-4524
US

V. Phone/Fax

Practice location:
  • Phone: 586-488-1400
  • Fax: 844-276-4323
Mailing address:
  • Phone: 248-593-1990
  • Fax: 248-593-9120

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: PRESIDENT
Credential:
Phone: 248-593-1990