=====================================================
General NPI Number Information
=====================================================
NPI Number | 1467735977
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | VAN DYKE PARTNERS LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/21/2011
-----------------------------------------------------
Last Update Date | 02/26/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 31800 VAN DYKE AVE
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48093-7907
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-264-9701
-----------------------------------------------------
Fax | 586-264-9702
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 30078 SCHOENHERR RD SUITE 300
-----------------------------------------------------
City | WARREN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48088-3179
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 586-563-1500
-----------------------------------------------------
Fax | 568-563-1200
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF OPERATIONS
-----------------------------------------------------
Name | MR. VIJAY SHENOY
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 586-563-1500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 1070000483
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------