Basic Information
| Provider Information | |||||||||
| NPI: | 1932293073 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | TRINITY CONTINUING CARE SERVICES | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | SANCTUARY AT THE PARK | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 9184 | ||||||||
| Address2: | |||||||||
| City: | FARMINGTON HILLS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 483339184 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7345428300 | ||||||||
| FaxNumber: | 7345428384 | ||||||||
| Practice Location | |||||||||
| Address1: | 570 HARVEY ST | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494422308 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317739121 | ||||||||
| FaxNumber: | 2317773983 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/03/2006 | ||||||||
| LastUpdateDate: | 02/09/2015 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ROBBINS | ||||||||
| AuthorizedOfficialFirstName: | KEN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7345428348 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 314000000X | 614110 | MI | Y | Nursing & Custodial Care Facilities | Skilled Nursing Facility |
ID Information
| ID | Type | State | Issuer | Description | 60-2623876 | 05 | MI | MEDICAID | 09966 | 01 | MI | BCBSM | OTHER |