=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700086683
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CROSBY MANOR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/19/2007
-----------------------------------------------------
Last Update Date | 07/19/2007
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5150 EAST G AVE
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49004-9553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-373-6264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5150 EAST G AVE
-----------------------------------------------------
City | KALAMAZOO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49004
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 269-373-6264
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADMINISTRATOR
-----------------------------------------------------
Name | MILDRED THIGPEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 269-373-6264
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 311ZA0620X
-----------------------------------------------------
Taxonomy Name | Adult Care Home Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------