1912914797 NPI number — KALAMAZOO LONG TERM CARE LLC

Table of content: GWEN MCMILLAN ACNP (NPI 1093045254)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912914797 NPI number — KALAMAZOO LONG TERM CARE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
KALAMAZOO LONG TERM CARE 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:
KALAMAZOO LONG TERM CARE
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:
1912914797
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/07/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 87
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
RICHLAND
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49083-0087
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-388-4850
Provider Business Mailing Address Fax Number:
269-388-4870

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1000 S BURDICK ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
KALAMAZOO
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49001-2734
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-388-4850
Provider Business Practice Location Address Fax Number:
269-388-4870
Provider Enumeration Date:
08/02/2006

Additional Information

Authorized Official

Authorized Official Last Name:
NELSON
Authorized Official First Name:
ERIK
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
269-388-4850

Provider Taxonomy Codes

  • Taxonomy code: 3336L0003X , with the licence number:  5301008411 , 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: 2368505 . This is a "NCPDP PROVIDER IDENTIFICATION NUMBER" identifier . This identifiers is of the category "OTHER".




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