Healthcare Provider Details

I. General information

NPI: 1376651489
Provider Name (Legal Business Name): MATRIX LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2006
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1603 MOMENTUM PL
CHICAGO IL
60689-5316
US

IV. Provider business mailing address

3075 ORCHARD VISTA DR SE STE. 100
GRAND RAPIDS MI
49546-7069
US

V. Phone/Fax

Practice location:
  • Phone: 616-975-5209
  • Fax: 616-588-0971
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number StateMI

VIII. Authorized Official

Name: MRS. DIANNE MATEJA
Title or Position: DIRECTOR OF SUB ACUTE SERVICES
Credential: RN
Phone: 616-957-3957