=====================================================
General NPI Number Information
=====================================================
NPI Number | 1104872977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | LAUREL HEALTH CARE COMPANY OF PERRINTON
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/25/2006
-----------------------------------------------------
Last Update Date | 09/08/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | RFD #1 4735 RANGER RD
-----------------------------------------------------
City | PERRINTON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48871
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-236-5433
-----------------------------------------------------
Fax | 989-236-7672
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4000 TOWN CTR STE 2000
-----------------------------------------------------
City | SOUTHFIELD
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48075-1415
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-386-0300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CFO
-----------------------------------------------------
Name | ANIS KHAN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-386-0300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 313M00000X
-----------------------------------------------------
Taxonomy Name | Nursing Facility/Intermediate Care Facility
-----------------------------------------------------
License Number | 294010
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 294010
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------