Healthcare Provider Details

I. General information

NPI: 1790835296
Provider Name (Legal Business Name): BEACON SPECIALIZED LIVING SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2007
Last Update Date: 03/31/2015
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 P.O. BOX 69
BANGOR MI
49013-1464
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-8400
  • Fax: 269-427-6027
Mailing address:
  • Phone: 269-427-8400
  • Fax: 269-427-6027

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: KEN RATZLAFF
Title or Position: PRESIDENT, CEO
Credential:
Phone: 269-427-8400