Healthcare Provider Details

I. General information

NPI: 1144743907
Provider Name (Legal Business Name): BENTON HARBOR OPCO II LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2017
Last Update Date: 05/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1385 E EMPIRE AVE
BENTON HARBOR MI
49022-2037
US

IV. Provider business mailing address

1385 E EMPIRE AVE
BENTON HARBOR MI
49022-2037
US

V. Phone/Fax

Practice location:
  • Phone: 269-925-0033
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LEONID BERKOVICH
Title or Position: AUTHORIZED REP
Credential:
Phone: 773-704-6341