Healthcare Provider Details

I. General information

NPI: 1972557460
Provider Name (Legal Business Name): HOLLAND HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 03/10/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1450 EAST FULTON
GRAND RAPIDS MI
49503-3854
US

IV. Provider business mailing address

1450 EAST FULTON
GRAND RAPIDS MI
49503-3854
US

V. Phone/Fax

Practice location:
  • Phone: 616-643-2600
  • Fax: 616-643-2623
Mailing address:
  • Phone: 616-643-2600
  • Fax: 616-643-2623

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number14196
License Number StateMI

VIII. Authorized Official

Name: MR. DAVID TIESENGA
Title or Position: CFO
Credential:
Phone: 616-235-5035