Provider Demographics
NPI:1669479804
Name:DECKERVILLE NURSING CENTER, LLC
Entity Type:Organization
Organization Name:DECKERVILLE NURSING CENTER, LLC
Other - Org Name:AUTUMNWOOD OF DECKERVILLE
Other - Org Type:Doing Business As
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 1:3387 ELLA
Mailing Address - Street 2:
Mailing Address - City:DECKERVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48427-9441
Mailing Address - Country:US
Mailing Address - Phone:810-376-2145
Mailing Address - Fax:810-376-4093
Practice Address - Street 1:3387 ELLA
Practice Address - Street 2:
Practice Address - City:DECKERVILLE
Practice Address - State:MI
Practice Address - Zip Code:48427-9441
Practice Address - Country:US
Practice Address - Phone:810-376-2145
Practice Address - Fax:810-376-4093
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIENA HEALTHCARE MANAGEMENT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-01
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4152673Medicaid
MIS9515OtherBCBSM
235446Medicare Oscar/Certification