=====================================================
General NPI Number Information
=====================================================
NPI Number | 1568552560
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ADVANCE NURSING CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/13/2006
-----------------------------------------------------
Last Update Date | 06/16/2008
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2936 JOHN DALY ST
-----------------------------------------------------
City | INKSTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48141-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-278-7272
-----------------------------------------------------
Fax | 313-278-8355
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2936 JOHN DALY ST
-----------------------------------------------------
City | INKSTER
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48141-2421
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 313-278-7272
-----------------------------------------------------
Fax | 313-278-8355
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MRS. ROBERTA SUE CAURDY
-----------------------------------------------------
Credential | NHA
-----------------------------------------------------
Telephone | 313-278-7272
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 824010
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------