Basic Information
Provider Information | |||||||||
NPI: | 1457699043 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | FARMINGTON NURSING, LLC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | WHITE PINE REHABILITATION & HEALTHCARE OF FARMINGTON | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 IONIA AVE SW STE 506 | ||||||||
Address2: | WHITE PINE MANAGEMENT, LLC C/O BIG BAY VENTURES, LLC | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495034179 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3019911388 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 34225 GRAND RIVER AVE | ||||||||
Address2: |   | ||||||||
City: | FARMINGTON | ||||||||
State: | MI | ||||||||
PostalCode: | 483353440 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2484777373 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 01/17/2013 | ||||||||
LastUpdateDate: | 01/17/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | BOLT | ||||||||
AuthorizedOfficialFirstName: | BRETTON | ||||||||
AuthorizedOfficialMiddleName: | J | ||||||||
AuthorizedOfficialTitleorPosition: | CEO | ||||||||
AuthorizedOfficialTelephone: | 3019911388 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X |   |   | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
No ID Information.