1417398595 NPI number — SPRING LAKE COMPASSIONATE LIVING

Table of content: (NPI 1417398595)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1417398595 NPI number — SPRING LAKE COMPASSIONATE LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
SPRING LAKE COMPASSIONATE LIVING
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:
1417398595
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/18/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
16609 VILLA PKWY
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPRING LAKE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49456-8835
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-414-5006
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
16609 VILLA PKWY
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPRING LAKE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49456-8835
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-414-5006
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
07/17/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
MODDERMAN
Authorized Official First Name:
DANIEL
Authorized Official Middle Name:
JAY
Authorized Official Title or Position:
DESIGNEE
Authorized Official Telephone Number:
616-334-6262

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AS700321868 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 320700000X , with the licence number: AS700321868 , 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)