Basic Information
| Provider Information | |||||||||
| NPI: | 1265510473 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ORCHARD GROVE HEATHCARE CENTER | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 NEW LAGRANGE RD STE 100 | ||||||||
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| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402224870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298062 | ||||||||
| FaxNumber: | 5024295980 | ||||||||
| Practice Location | |||||||||
| Address1: | 1385 E EMPIRE AVE | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490222037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2699250033 | ||||||||
| FaxNumber: | 2699252019 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| AuthorizedOfficialLastName: | TSCHUDI | ||||||||
| AuthorizedOfficialFirstName: | ALLEN | ||||||||
| AuthorizedOfficialMiddleName: | CRAIG | ||||||||
| AuthorizedOfficialTitleorPosition: | MANAGING MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 5024298062 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 114150 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 4549277 | 05 | MI | MEDICAID |