1639313174 NPI number — BRONSON LAKEVIEW HOSPITAL

Table of content: (NPI 1639313174)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1639313174 NPI number — BRONSON LAKEVIEW HOSPITAL

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BRONSON LAKEVIEW HOSPITAL
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:
BRONSON LAKEVIEW HOSPITAL BEHAVIORAL HEALTH
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:
1639313174
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/14/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
301 JOHN ST
Provider Second Line Business Mailing Address:
BOX 42
Provider Business Mailing Address City Name:
KALAMAZOO
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49007-5295
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-341-7806
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
404 HAZEN ST
Provider Second Line Business Practice Location Address:
SUITE L3
Provider Business Practice Location Address City Name:
PAW PAW
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49079-1040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-657-1595
Provider Business Practice Location Address Fax Number:
269-657-1534
Provider Enumeration Date:
04/28/2009

Additional Information

Authorized Official

Authorized Official Last Name:
EAST
Authorized Official First Name:
REBECCA
Authorized Official Middle Name:
Authorized Official Title or Position:
SVP,CFO
Authorized Official Telephone Number:
269-341-6000

Provider Taxonomy Codes

  • Taxonomy code: 103TC0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 1041C0700X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 0H010630 . This is a "BCBSM" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




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