1750618443 NPI number — EVERGREEN TERRACE ASSISTED LIVING

Table of content: (NPI 1750618443)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1750618443 NPI number — EVERGREEN TERRACE ASSISTED LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
EVERGREEN TERRACE ASSISTED LIVING
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:
1750618443
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/17/2009
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:
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:
616-464-1564
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
801 FULLER AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BIG RAPIDS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49307-2106
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-527-1050
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
11/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
MICHALSKI
Authorized Official First Name:
WENDI
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
231-527-1050

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL540279286 , 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: 23D1102189 . This is a "CLIA" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com