Basic Information
Provider Information
NPI: 1184073397
EntityType: 2
ReplacementNPI:  
OrganizationName: GLADWIN PINES OPERATING, LLC
LastName:  
FirstName:  
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName: GLADWIN PINES NURSING AND REHABILITATION CENTER
OtherOrganizationType: 3
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 2532 W CADILLAC DR
Address2: P.O. BOX 579
City: FARWELL
State: MI
PostalCode: 486229757
CountryCode: US
TelephoneNumber: 9895883547
FaxNumber:  
Practice Location
Address1: 449 QUARTER ST
Address2:  
City: GLADWIN
State: MI
PostalCode: 486241918
CountryCode: US
TelephoneNumber: 9894263430
FaxNumber:  
Other Information
ProviderEnumerationDate: 06/08/2016
LastUpdateDate: 06/08/2016
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode:  
AuthorizedOfficialLastName: THOMPSON
AuthorizedOfficialFirstName: BRIAN
AuthorizedOfficialMiddleName: DOYLE
AuthorizedOfficialTitleorPosition: CHIEF FINANCIAL OFFICER
AuthorizedOfficialTelephone: 9895883547
IsSoleProprietor:  
IsOrganizationSubpart: N
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix: MR.
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
314000000X MIY Nursing & Custodial Care FacilitiesSkilled Nursing Facility 

No ID Information.


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