Basic Information
| Provider Information | |||||||||
| NPI: | 1053609800 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHWEST SNF LLC | ||||||||
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| OtherOrganizationName: | NORTHWEST NURSING AND REHABILATATION CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 PONTIAC RD | ||||||||
| Address2: | |||||||||
| City: | EAST GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 49506 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4601 PALL MALL RD | ||||||||
| Address2: | |||||||||
| City: | BALTIMORE | ||||||||
| State: | MD | ||||||||
| PostalCode: | 21215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4106645551 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/14/2011 | ||||||||
| LastUpdateDate: | 09/30/2022 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | BOLT | ||||||||
| AuthorizedOfficialFirstName: | BRETTON | ||||||||
| AuthorizedOfficialMiddleName: | J | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 3019911388 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WHOLLY OWNED BY WP NURSING PARENT | ||||||||
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| NPICertificationDate: | 09/30/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.