Healthcare Provider Details

I. General information

NPI: 1750718078
Provider Name (Legal Business Name): WILDS RIVER REST
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/01/2013
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12409 N RED BUD TRL
BUCHANAN MI
49107-9139
US

IV. Provider business mailing address

12409 N RED BUD TRL
BUCHANAN MI
49107-9139
US

V. Phone/Fax

Practice location:
  • Phone: 269-695-6074
  • Fax: 269-697-0474
Mailing address:
  • Phone: 269-695-6074
  • Fax: 269-697-0474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAM110064771
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code311Z00000X
TaxonomyCustodial Care Facility
License NumberAM110064771
License Number StateMI

VIII. Authorized Official

Name: MS. JANICE ELLEN WILDS
Title or Position: OWNER
Credential:
Phone: 269-695-6074