Basic Information
Provider Information | |||||||||
NPI: | 1841298288 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | ATRIUM CENTREVILLE INC. | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: | FAIRVIEW NURSING AND REHABILITATION COMMUNITY | ||||||||
OtherOrganizationType: | 3 | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
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: | 441 E MAIN ST | ||||||||
Address2: |   | ||||||||
City: | CENTREVILLE | ||||||||
State: | MI | ||||||||
PostalCode: | 490329626 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2694679575 | ||||||||
FaxNumber: | 2694677077 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/11/2005 | ||||||||
LastUpdateDate: | 02/13/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | LOCKHART | ||||||||
AuthorizedOfficialFirstName: | DENNIS | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | CHIEF ACCOUNTING OFFICER | ||||||||
AuthorizedOfficialTelephone: | 6144160600 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 310400000X | AH750236782 | MI | N |   | Nursing & Custodial Care Facilities | Assisted Living Facility |   | 314000000X | 75-4010 | MI | Y |   | Nursing & Custodial Care Facilities | Skilled Nursing Facility |   |
ID Information
ID | Type | State | Issuer | Description | 09715 | 01 | MI | BCBS PROVIDER CODE | OTHER | 60 3079677 | 05 | MI |   | MEDICAID |