1235141151 NPI number — CASCADE CARE CENTER, INC

Table of content: (NPI 1235141151)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1235141151 NPI number — CASCADE CARE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASCADE CARE CENTER, 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:
Provider Other Organization Name Type Code:
6
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:
1235141151
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4630 PLAINFIELD AVENUE NE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-957-3957
Provider Business Mailing Address Fax Number:
616-957-1556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1095 MEDICAL PARK DR SE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49546-3607
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-949-7220
Provider Business Practice Location Address Fax Number:
616-956-6947
Provider Enumeration Date:
08/12/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DOOD
Authorized Official First Name:
J
Authorized Official Middle Name:
LINDSEY
Authorized Official Title or Position:
EXECUTIVE VICE PRESIDENT / CFO
Authorized Official Telephone Number:
616-975-5287

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  414330 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2086096 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 9828 . This is a "BLUE CROSS" identifier . This identifiers is of the category "OTHER".




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