MEDICARE: BOULEVARD MANOR L.L.C.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1063712586
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	BOULEVARD MANOR L.L.C.

Provider Business Mailing Address
First Line	:	2920 OAKWOOD BLVD
Second Line	:	SUITE B
City	:	MELVINDALE
State	:	MI
Zip	:	48122-1244
Country	:	US
Telephone Number	:	313-579-2255
Fax Number	:	313-579-5756

Provider Business Practice Location Address
First Line	:	464 E GRAND BLVD
Second Line	:
City	:	DETROIT
State	:	MI
Zip	:	48207-3637
Country	:	US
Telephone Number	:	313-579-2255
Fax Number	:	313-579-5756

Authorized Official
Title or Position	:	AUTHORIZED MEMBER
Name	:	FAHIM UDDIN
Credential	:
Telephone Number	:	313-579-2255

Provider Enumeration Date	:	11/01/2010
Last Update Date	:	04/20/2011

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