Provider Demographics
NPI:1700165834
Name:GENESEE MANOR INC
Entity Type:Organization
Organization Name:GENESEE MANOR INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:WESLEY
Authorized Official - Last Name:RAY
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:313-449-6895
Mailing Address - Street 1:19158 SANTA ROSA DR
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48221-1732
Mailing Address - Country:US
Mailing Address - Phone:313-449-6895
Mailing Address - Fax:313-945-6591
Practice Address - Street 1:19415 PURLINGBROOK ST
Practice Address - Street 2:
Practice Address - City:LIVONIA
Practice Address - State:MI
Practice Address - Zip Code:48152-1950
Practice Address - Country:US
Practice Address - Phone:313-449-6895
Practice Address - Fax:313-345-6591
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-08-07
Last Update Date:2011-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS820294980251E00000X, 310400000X, 3104A0625X, 3104A0630X, 311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home