Provider Demographics
NPI:1801883632
Name:SHANTA CORPORATION
Entity type:Organization
Organization Name:SHANTA CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:BEAUVAIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-886-2500
Mailing Address - Street 1:6232 CADIEUX RD
Mailing Address - Street 2:
Mailing Address - City:DETROIT
Mailing Address - State:MI
Mailing Address - Zip Code:48224-3812
Mailing Address - Country:US
Mailing Address - Phone:313-886-2500
Mailing Address - Fax:
Practice Address - Street 1:6232 CADIEUX RD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48224-3812
Practice Address - Country:US
Practice Address - Phone:313-886-2500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-06
Last Update Date:2011-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIMI834710314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235415OtherMEDICARE
MI1548356Medicaid
MIMI834710OtherSTATE LICENSE NUMBER
MI1548356Medicaid