Provider Demographics
NPI:1063712586
Name:BOULEVARD MANOR L.L.C.
Entity type:Organization
Organization Name:BOULEVARD MANOR L.L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:FAHIM
Authorized Official - Middle Name:
Authorized Official - Last Name:UDDIN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-579-2255
Mailing Address - Street 1:2920 OAKWOOD BLVD
Mailing Address - Street 2:SUITE B
Mailing Address - City:MELVINDALE
Mailing Address - State:MI
Mailing Address - Zip Code:48122-1244
Mailing Address - Country:US
Mailing Address - Phone:313-579-2255
Mailing Address - Fax:313-579-5756
Practice Address - Street 1:464 E GRAND BLVD
Practice Address - Street 2:
Practice Address - City:DETROIT
Practice Address - State:MI
Practice Address - Zip Code:48207-3637
Practice Address - Country:US
Practice Address - Phone:313-579-2255
Practice Address - Fax:313-579-5756
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-11-01
Last Update Date:2011-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235242Medicare Oscar/Certification