Provider Demographics
NPI:1417171844
Name:THE LAURELS OF CARSON CITY, LLC
Entity Type:Organization
Organization Name:THE LAURELS OF CARSON CITY, LLC
Other - Org Name:THE LAURELS OF CARSON CITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ANIS
Authorized Official - Middle Name:
Authorized Official - Last Name:KHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-386-0300
Mailing Address - Street 1:4000 TOWN CTR
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-1410
Mailing Address - Country:US
Mailing Address - Phone:248-386-0300
Mailing Address - Fax:
Practice Address - Street 1:620 N. SECOND STREET
Practice Address - Street 2:
Practice Address - City:CARSON CITY
Practice Address - State:MI
Practice Address - Zip Code:48811
Practice Address - Country:US
Practice Address - Phone:614-794-8800
Practice Address - Fax:614-794-8826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-04-13
Last Update Date:2021-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI594041314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5256082Medicaid
MI5256082Medicaid