1336451145 NPI number — LEISURE LIVING MANAGEMENT OF FREMONT, 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 1336451145 NPI number — LEISURE LIVING MANAGEMENT OF FREMONT, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
LEISURE LIVING MANAGEMENT OF FREMONT, 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:
FOUNTAIN VIEW OF FREMONT - LABORATORY
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:
1336451145
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/09/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 HILLCREST AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FREMONT
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49412-1348
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-924-5050
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 HILLCREST AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FREMONT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49412-1348
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-924-5050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/09/2010

Additional Information

Authorized Official

Authorized Official Last Name:
NOBEL
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
231-924-5050

Provider Taxonomy Codes

  • Taxonomy code: 291U00000X , with the licence number:  23D0975403 , 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)





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