Basic Information
| Provider Information | |||||||||
| NPI: | 1538167630 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CCG LAKESHORE INC | ||||||||
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| OtherOrganizationName: | RIVERSIDE NURSING AND REHABILITATION COMMUNITY | ||||||||
| 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: | 2317996870 | ||||||||
| FaxNumber: | 2317990250 | ||||||||
| Practice Location | |||||||||
| Address1: | 415 FRIANT ST | ||||||||
| Address2: | |||||||||
| City: | GRAND HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494172311 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6168424120 | ||||||||
| FaxNumber: | 6168428742 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/12/2005 | ||||||||
| LastUpdateDate: | 01/06/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | FERKANY | ||||||||
| AuthorizedOfficialFirstName: | JAMES | ||||||||
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| AuthorizedOfficialTitleorPosition: | SECRETARY | ||||||||
| AuthorizedOfficialTelephone: | 6144546048 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CCG LAKESHORE INC | ||||||||
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| NPICertificationDate: | 01/06/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 70-4090 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 09621 | 01 | MI | BCBS PROVIDER CODE | OTHER | 60 2154623 | 05 | MI | MEDICAID |