1093726234 NPI number — PINE REST CHRISTIAN MENTAL HEALTH SERVICES

Table of content: (NPI 1093726234)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1093726234 NPI number — PINE REST CHRISTIAN MENTAL HEALTH SERVICES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINE REST CHRISTIAN MENTAL HEALTH SERVICES
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:
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:
1093726234
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
300 68TH ST SE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49548-6927
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-455-5000
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1530 NICHOLS RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49006-2065
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-343-6700
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/11/2006

Additional Information

Authorized Official

Authorized Official Last Name:
FENNEMA
Authorized Official First Name:
DIANE
Authorized Official Middle Name:
Authorized Official Title or Position:
MANAGED CARE ADMINISTRATOR
Authorized Official Telephone Number:
616-281-6372

Provider Taxonomy Codes

  • Taxonomy code: 103T00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 104100000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 2084P0800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 363L00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 260D17625 . This is a "PSYCHIATRISTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 680D16189 . This is a "PSYCHOLOGISTS" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".
  • Identifier: 800D16222 . This is a "SOCIAL WORKERS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 500D11133 . This is a "NURSE PRACTIONERS" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: P10D11275 . This is a "MA, LLP/ DOCTORAL" identifier , issued by the state of ( MA ) . This identifiers is of the category "OTHER".




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