MEDICARE: KITH HAVEN ACQUISITION COMPANY, LLC

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

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	09672	OTHER	MI	BCBSM
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164429221
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	KITH HAVEN ACQUISITION COMPANY, LLC

Provider Business Mailing Address
First Line	:	G1069 N BALLENGER HWY
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48504-4431
Country	:	US
Telephone Number	:	810-235-6676
Fax Number	:	810-235-9172

Provider Business Practice Location Address
First Line	:	G1069 N BALLENGER HWY
Second Line	:
City	:	FLINT
State	:	MI
Zip	:	48504-4431
Country	:	US
Telephone Number	:	810-235-6676
Fax Number	:	810-235-9172

Authorized Official
Title or Position	:	CEO
Name	:	MISS MOHAMMAD ASHRAF QAZI
Credential	:
Telephone Number	:	248-386-0300

Provider Enumeration Date	:	07/05/2005
Last Update Date	:	12/27/2011

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