1912330457 NPI number — BAYFIELD ASSISTED LIVING

Table of content: (NPI 1912330457)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1912330457 NPI number — BAYFIELD ASSISTED LIVING

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
BAYFIELD 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:
1912330457
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/09/2015
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:
616-464-1564
Provider Business Mailing Address Fax Number:
616-464-2470

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
3932 MONITOR RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
BAY CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48706-9298
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-684-9600
Provider Business Practice Location Address Fax Number:
989-684-9800
Provider Enumeration Date:
08/20/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
THELEN
Authorized Official First Name:
SAMANTHA
Authorized Official Middle Name:
Authorized Official Title or Position:
DIRECTOR OF OPERATIONS
Authorized Official Telephone Number:
616-719-5895

Provider Taxonomy Codes

  • Taxonomy code: 302F00000X , with the licence number:  AH090323912 , 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: AH800315846 , 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)