1497753834 NPI number — ATRIUM COUNTRYSIDE LLC

Table of content: (NPI 1497753834)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497753834 NPI number — ATRIUM COUNTRYSIDE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ATRIUM COUNTRYSIDE LLC
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:
COUNTRYSIDE NURSING AND REHABILITATION COMMUNITY
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:
1497753834
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/13/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5000 HAKES DR
Provider Second Line Business Mailing Address:
SUITE 600
Provider Business Mailing Address City Name:
NORTON SHORES
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49441-5574
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-799-6870
Provider Business Mailing Address Fax Number:
231-799-0250

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
120 BASELINE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH HAVEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49090-1037
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-637-8411
Provider Business Practice Location Address Fax Number:
269-637-8460
Provider Enumeration Date:
07/11/2005

Additional Information

Authorized Official

Authorized Official Last Name:
LOCKHART
Authorized Official First Name:
DENNIS
Authorized Official Middle Name:
Authorized Official Title or Position:
CHIEF ACCOUNTING OFFICER
Authorized Official Telephone Number:
614-416-0600

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AH800236748 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 314000000X , with the licence number: 80-4050 , 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)

  • Identifier: S 9517 . This is a "BCBS PROVIDER CODE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 60 4191457 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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