Provider Demographics
NPI:1871088898
Name:PINE CREEK MANOR SKILLED NURSING & REHAB CENTER LLC
Entity type:Organization
Organization Name:PINE CREEK MANOR SKILLED NURSING & REHAB CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SOLE 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:313-549-7708
Mailing Address - Street 1:30700 TELEGRAPH RD STE 2504
Mailing Address - Street 2:
Mailing Address - City:BINGHAM FARMS
Mailing Address - State:MI
Mailing Address - Zip Code:48025-4571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:34330 VAN BORN RD
Practice Address - Street 2:
Practice Address - City:WAYNE
Practice Address - State:MI
Practice Address - Zip Code:48184-2472
Practice Address - Country:US
Practice Address - Phone:248-229-1331
Practice Address - Fax:248-593-9120
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-06-22
Last Update Date:2018-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility