1992896104 NPI number — BRONSON AT HOME

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 1992896104 NPI number — BRONSON AT HOME

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRONSON AT HOME
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:
LIFESPAN, INC
Provider Other Organization Name Type Code:
4
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:
1992896104
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 JOHN ST
Provider Second Line Business Mailing Address:
BOX 42
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49007-5295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-341-7806
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
165 WASHINGTON AVE N
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BATTLE CREEK
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49037-2929
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-660-3600
Provider Business Practice Location Address Fax Number:
269-660-3650
Provider Enumeration Date:
09/27/2006

Additional Information

Authorized Official

Authorized Official Last Name:
EAST
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP, CFO
Authorized Official Telephone Number:
269-341-6000

Provider Taxonomy Codes

  • Taxonomy code: 251E00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 4368324 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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