Healthcare Provider Details

I. General information

NPI: 1396975546
Provider Name (Legal Business Name): PORTER HILLS PRESBYTERIAN VILLAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/22/2009
Last Update Date: 09/03/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1029 E PARIS AVE SE
GRAND RAPIDS MI
49546-3603
US

IV. Provider business mailing address

4450 CASCADE RD SE STE 200
GRAND RAPIDS MI
49546-8330
US

V. Phone/Fax

Practice location:
  • Phone: 616-301-6209
  • Fax:
Mailing address:
  • Phone: 616-949-4975
  • 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: LORI A POTTER
Title or Position: COO
Credential: RN
Phone: 616-893-3017