Basic Information
| Provider Information | |||||||||
| NPI: | 1154754034 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | NORTHCREST OPERATING CO.,INC. | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | NORTHCREST ASSISTED LIVING | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5000 HAKES DR | ||||||||
| Address2: | SUITE 600 | ||||||||
| City: | NORTON SHORES | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494415574 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317996882 | ||||||||
| FaxNumber: | 2317990250 | ||||||||
| Practice Location | |||||||||
| Address1: | 2650 RUDDIMAN DR | ||||||||
| Address2: | |||||||||
| City: | NORTH MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494453260 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317442447 | ||||||||
| FaxNumber: | 2317442448 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/15/2013 | ||||||||
| LastUpdateDate: | 09/17/2013 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | REESE | ||||||||
| AuthorizedOfficialFirstName: | JASON | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | PRESIDENT & CHIEF OPERATING OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6144160600 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AH610236856 | MI | Y | Nursing & Custodial Care Facilities | Assisted Living Facility |
ID Information
| ID | Type | State | Issuer | Description | AH610236856 | 01 | MI | STATE OF MICHIGAN DEPARTMENT OF HUMAN SERVICES | OTHER |