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General NPI Number Information
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NPI Number | 1700165834
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Entity Type | Organization
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Legal Business Name | GENESEE MANOR INC
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Dates
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Enumeration Date | 08/07/2011
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Last Update Date | 08/07/2011
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Provider Practice Location Address
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Address Line | 19415 PURLINGBROOK ST
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City | LIVONIA
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State | MI
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Zip | 48152-1950
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Country | US
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Telephone | 313-449-6895
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Fax | 313-345-6591
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Provider Business Mailing Address
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Address Line | 19158 SANTA ROSA DR
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City | DETROIT
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State | MI
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Zip | 48221-1732
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Country | US
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Telephone | 313-449-6895
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Fax | 313-945-6591
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Authorized Official
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Title or Position | OWNER
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Name | GARY WESLEY RAY I
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Credential |
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Telephone | 313-449-6895
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AS820294980
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number | AS820294980
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License Number State | MI
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Taxonomy #3
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number | AS820294980
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License Number State | MI
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Taxonomy #4
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | AS820294980
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License Number State | MI
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Taxonomy #5
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | AS820294980
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License Number State | MI
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