1578681300 NPI number — BARUCH SLS, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578681300 NPI number — BARUCH SLS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BARUCH SLS, INC.
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:
FOUNTAINVIEW ASSISTED LIVING
Provider Other Organization Name Type Code:
3
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:
1578681300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3196 KRAFT AVE SE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49512-2078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-285-0573
Provider Business Mailing Address Fax Number:
616-464-2470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 W RANDALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOPERSVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49404-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-997-9253
Provider Business Practice Location Address Fax Number:
616-997-7234
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLAUSON
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
616-285-0573

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL700070219 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 310400000X , with the licence number: AL700070220 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X , with the licence number: AL700088278 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 5197796 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5197876 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23D0975401 . This is a "CLIA WAIVER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6967688 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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