Provider Demographics
NPI:1326299660
Name:GREENLEY SQUARE MANOR
Entity Type:Organization
Organization Name:GREENLEY SQUARE MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:DOUGLAS
Authorized Official - Last Name:BERTRAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:810-743-5011
Mailing Address - Street 1:1345 CONNELL ST
Mailing Address - Street 2:
Mailing Address - City:BURTON
Mailing Address - State:MI
Mailing Address - Zip Code:48529-2201
Mailing Address - Country:US
Mailing Address - Phone:810-743-5011
Mailing Address - Fax:810-743-7370
Practice Address - Street 1:1345 CONNELL ST
Practice Address - Street 2:
Practice Address - City:BURTON
Practice Address - State:MI
Practice Address - Zip Code:48529-2201
Practice Address - Country:US
Practice Address - Phone:810-743-5011
Practice Address - Fax:810-743-7370
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-06
Last Update Date:2008-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL250015221320600000X
MIAM250237981320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities