1114972734 NPI number — LAUREL HEALTH CARE COMPANY OF GALESBURG

Table of content: (NPI 1114972734)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114972734 NPI number — LAUREL HEALTH CARE COMPANY OF GALESBURG

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LAUREL HEALTH CARE COMPANY OF GALESBURG
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114972734
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/13/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4000 TOWN CTR STE 2000
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTHFIELD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48075-1415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-386-0300
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1080 N 35TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GALESBURG
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49053-9727
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-665-7043
Provider Business Practice Location Address Fax Number:
616-665-4080
Provider Enumeration Date:
05/23/2006

Additional Information

Authorized Official

Authorized Official Last Name:
KHAN
Authorized Official First Name:
ANIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
248-386-0300

Provider Taxonomy Codes

  • Taxonomy code: 313M00000X , with the licence number:  394150 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 394150 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 3319728 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 394150 . This is a "NURSING HOME LICENSE #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 09796 . This is a "BLUE CROSS BLUE SHIELD #" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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