Healthcare Provider Details

I. General information

NPI: 1215324876
Provider Name (Legal Business Name): BEACON SPECIALIZED LIVING SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/22/2015
Last Update Date: 01/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

555 RAILROAD ST
BANGOR MI
49013-1464
US

IV. Provider business mailing address

555 RAILROAD ST PO BOX 69
BANGOR MI
49013-1464
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-8400
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: NATHAN RATZLAFF
Title or Position: OWNER
Credential:
Phone: 269-427-8400