1578681300 NPI number — BARUCH SLS, INC.

Table of content: (NPI 1578681300)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578681300 NPI number — BARUCH SLS, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BARUCH SLS, 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:
FOUNTAINVIEW ASSISTED LIVING
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:
1578681300
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/10/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
3196 KRAFT AVE SE
Provider Second Line Business Mailing Address:
SUITE 200
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49512-2078
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-285-0573
Provider Business Mailing Address Fax Number:
616-464-2470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
640 W RANDALL ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
COOPERSVILLE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49404-1306
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-997-9253
Provider Business Practice Location Address Fax Number:
616-997-7234
Provider Enumeration Date:
03/27/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CLAUSON
Authorized Official First Name:
CONNIE
Authorized Official Middle Name:
L
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
616-285-0573

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL700070219 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 310400000X , with the licence number: AL700070220 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 310400000X , with the licence number: AL700088278 , 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: 5197796 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 5197876 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 23D0975401 . This is a "CLIA WAIVER ID" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 6967688 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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