Healthcare Provider Details

I. General information

NPI: 1518341221
Provider Name (Legal Business Name): BEACON SPECIALIZED LIVING SERVICES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/13/2015
Last Update Date: 07/13/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6418 DEANS HILL RD STE 2
BERRIEN CENTER MI
49102-9750
US

IV. Provider business mailing address

555 RAILROAD ST
BANGOR MI
49013-1464
US

V. Phone/Fax

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

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberAL110366290
License Number StateMI

VIII. Authorized Official

Name: GERALD WRIGHT
Title or Position: BUSINESS MANAGER
Credential:
Phone: 269-427-8400