=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407516305
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | NORTHVILLE MANOR LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/20/2021
-----------------------------------------------------
Last Update Date | 12/20/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 520 W MAIN ST
-----------------------------------------------------
City | NORTHVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48167-1529
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-349-4290
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30700 TELEGRAPH RD STE 2504
-----------------------------------------------------
City | BINGHAM FARMS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48025-4571
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 248-593-1990
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MEMBER
-----------------------------------------------------
Name | FAHIM UDDIN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 248-593-1990
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------