Healthcare Provider Details

I. General information

NPI: 1508082876
Provider Name (Legal Business Name): LEISURE LIVING MANAGEMENT OF BUCHANAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2007
Last Update Date: 08/13/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

809 CAROLL ST
BUCHANAN MI
49107-1738
US

IV. Provider business mailing address

809 CAROLL ST
BUCHANAN MI
49107-1738
US

V. Phone/Fax

Practice location:
  • Phone: 269-695-6655
  • Fax: 269-695-6673
Mailing address:
  • Phone: 269-695-6655
  • Fax: 269-695-6673

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberAL110065097
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL110081160
License Number StateMI

VIII. Authorized Official

Name: MICHELLE FIELDS
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 269-695-6655