Basic Information
| Provider Information | |||||||||
| NPI: | 1649855917 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | SOUTH HAVEN OPCO, LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7400 NEW LA GRANGE RD STE 100 | ||||||||
| Address2: | |||||||||
| City: | LOUISVILLE | ||||||||
| State: | KY | ||||||||
| PostalCode: | 402224870 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5024298062 | ||||||||
| FaxNumber: | 5024295980 | ||||||||
| Practice Location | |||||||||
| Address1: | 120 BASELINE RD | ||||||||
| Address2: | |||||||||
| City: | SOUTH HAVEN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490901037 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696378411 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2021 | ||||||||
| LastUpdateDate: | 03/17/2021 | ||||||||
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| AuthorizedOfficialLastName: | OHLSEN | ||||||||
| AuthorizedOfficialFirstName: | JONATHAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CHIEF LEGAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 5415431215 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | JD | ||||||||
| NPICertificationDate: | 03/17/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
No ID Information.