Basic Information
| Provider Information | |||||||||
| NPI: | 1134222318 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAIR ACRES NURSING HOME, INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | THE VILLAGE REHABILITATION AND CARE CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 22600 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ARMADA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480053237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867845322 | ||||||||
| FaxNumber: | 5867848779 | ||||||||
| Practice Location | |||||||||
| Address1: | 22600 W MAIN ST | ||||||||
| Address2: | |||||||||
| City: | ARMADA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480053237 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5867845322 | ||||||||
| FaxNumber: | 5867848779 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/06/2006 | ||||||||
| LastUpdateDate: | 09/08/2008 | ||||||||
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| AuthorizedOfficialLastName: | PRIES | ||||||||
| AuthorizedOfficialFirstName: | JEFFREY | ||||||||
| AuthorizedOfficialMiddleName: | E. | ||||||||
| AuthorizedOfficialTitleorPosition: | ADMINISTRATOR | ||||||||
| AuthorizedOfficialTelephone: | 5867845322 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 50-4060 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 1584263 | 05 | MI | MEDICAID | S9558 | 01 | MI | BLUE CROSS BLUE SHIELD OF MICHIGAN | OTHER |