Provider Demographics
NPI:1689805970
Name:BOULEVARD TEMPLE CARE CENTER, LLC
Entity Type:Organization
Organization Name:BOULEVARD TEMPLE CARE CENTER, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:MOHAMMAD
Authorized Official - Middle Name:A
Authorized Official - Last Name:QAZI
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:248-386-0300
Mailing Address - Street 1:2567 W GRAND BLVD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48208-1235
Mailing Address - Country:US
Mailing Address - Phone:313-895-5340
Mailing Address - Fax:313-895-5970
Practice Address - Street 1:2567 W GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48208-1235
Practice Address - Country:US
Practice Address - Phone:313-895-5340
Practice Address - Fax:313-895-5970
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CIENA HEALTHCARE MANAGEMENT, INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-08-04
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2153377Medicaid
235498Medicare Oscar/Certification