Basic Information
| Provider Information | |||||||||
| NPI: | 1275511487 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | BLUE WATER NURSING CENTER | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
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| OtherOrganizationName: | EVANGELICAL HOME - PORT HURON | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5635 LAKESHORE RD | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480592817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103857447 | ||||||||
| FaxNumber: | 8103857114 | ||||||||
| Practice Location | |||||||||
| Address1: | 5635 LAKESHORE RD | ||||||||
| Address2: | |||||||||
| City: | FORT GRATIOT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 480592817 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8103857447 | ||||||||
| FaxNumber: | 8103857114 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/06/2006 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | PETROSKEY | ||||||||
| AuthorizedOfficialFirstName: | LAWRENCE | ||||||||
| AuthorizedOfficialMiddleName: | G | ||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 3138363499 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 744060 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.