Healthcare Provider Details

I. General information

NPI: 1568554566
Provider Name (Legal Business Name): COVENANT LIVING OF THE GREAT LAKES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/28/2006
Last Update Date: 01/28/2020
Certification Date: 01/28/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2520 LAKE MICHIGAN DRIVE NW
GRAND RAPIDS MI
49504-4696
US

IV. Provider business mailing address

2520 LAKE MICHIGAN DRIVE NW
GRAND RAPIDS MI
49504-4696
US

V. Phone/Fax

Practice location:
  • Phone: 616-735-4541
  • Fax: 616-735-5900
Mailing address:
  • Phone: 616-735-4541
  • Fax: 616-735-5900

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number414382
License Number StateMI

VIII. Authorized Official

Name: ELIZABETH MCLAREN
Title or Position: ASSOCIATE VICE PRESIDENT OF HEALTH
Credential:
Phone: 773-878-4430