1538167630 NPI number — CCG LAKESHORE INC

Table of content: (NPI 1538167630)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1538167630 NPI number — CCG LAKESHORE INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CCG LAKESHORE 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:
RIVERSIDE 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:
1538167630
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/06/2020
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:
415 FRIANT ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAND HAVEN
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49417-2311
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-842-4120
Provider Business Practice Location Address Fax Number:
616-842-8742
Provider Enumeration Date:
07/12/2005

Additional Information

Authorized Official

Authorized Official Last Name:
FERKANY
Authorized Official First Name:
JAMES
Authorized Official Middle Name:
Authorized Official Title or Position:
SECRETARY
Authorized Official Telephone Number:
614-454-6048

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  70-4090 , 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: 09621 . This is a "BCBS PROVIDER CODE" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 60 2154623 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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