Provider Demographics
NPI:1497364442
Name:BOLTON BROOK MANOR
Entity Type:Organization
Organization Name:BOLTON BROOK MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:SUNIL
Authorized Official - Middle Name:R
Authorized Official - Last Name:BHATTAD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-797-8519
Mailing Address - Street 1:4554 THOMAS RD
Mailing Address - Street 2:
Mailing Address - City:METAMORA
Mailing Address - State:MI
Mailing Address - Zip Code:48455-9220
Mailing Address - Country:US
Mailing Address - Phone:810-678-2087
Mailing Address - Fax:810-678-2766
Practice Address - Street 1:4554 THOMAS RD
Practice Address - Street 2:
Practice Address - City:METAMORA
Practice Address - State:MI
Practice Address - Zip Code:48455-9220
Practice Address - Country:US
Practice Address - Phone:810-678-2087
Practice Address - Fax:810-678-2766
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-07-27
Last Update Date:2020-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home