1780678367 NPI number — CEDAR CARE CENTER, 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 1780678367 NPI number — CEDAR CARE CENTER, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CEDAR CARE CENTER, 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:
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:
1780678367
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/10/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4630 PLAINFIELD AVENUE NE
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49525
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
616-957-3975
Provider Business Mailing Address Fax Number:
616-957-1556

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
400 JEFFERY ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CEDAR SPRINGS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49319-9572
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-696-0170
Provider Business Practice Location Address Fax Number:
616-696-4884
Provider Enumeration Date:
09/09/2005

Additional Information

Authorized Official

Authorized Official Last Name:
DOOD
Authorized Official First Name:
J
Authorized Official Middle Name:
LINDSEY
Authorized Official Title or Position:
CFO
Authorized Official Telephone Number:
616-975-5287

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  414360 , 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: 1786240 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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