Provider Demographics
NPI:1598816423
Name:ROYALTON MANOR, LLC
Entity Type:Organization
Organization Name:ROYALTON MANOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:ASHRAF
Authorized Official - Last Name:QAZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-386-0300
Mailing Address - Street 1:288 PEACE BOULEVARD
Mailing Address - Street 2:
Mailing Address - City:ST JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:288 PEACE BOULEVARD
Practice Address - Street 2:
Practice Address - City:ST JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085
Practice Address - Country:US
Practice Address - Phone:269-556-9050
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIENA HEALTHCARE MANAGEMENT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-01-16
Last Update Date:2010-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5184958Medicaid
09792OtherBCBSM
235623Medicare Oscar/Certification