Provider Demographics
NPI:1164772646
Name:HERITAGE MANOR NURSING & REHAB CENTER
Entity Type:Organization
Organization Name:HERITAGE MANOR NURSING & REHAB CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:UDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-593-1990
Mailing Address - Street 1:30700 TELEGRAPH RD
Mailing Address - Street 2:SUITE 2504
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4524
Mailing Address - Country:US
Mailing Address - Phone:248-593-1990
Mailing Address - Fax:248-593-9120
Practice Address - Street 1:9500 GRAND RIVER AVE
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48204-2132
Practice Address - Country:US
Practice Address - Phone:313-491-7920
Practice Address - Fax:313-491-0510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-12
Last Update Date:2013-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235234Medicare Oscar/Certification