Healthcare Provider Details

I. General information

NPI: 1326013830
Provider Name (Legal Business Name): PORTER HILLS PRESBYTERIAN VILLAGE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/19/2006
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3600 E FULTON STREET
GRAND RAPIDS MI
49546-1322
US

IV. Provider business mailing address

4450 CASCADE ROAD SE SUITE 200
GRAND RAPIDS MI
49546-8330
US

V. Phone/Fax

Practice location:
  • Phone: 616-949-4971
  • Fax: 616-974-1986
Mailing address:
  • Phone: 616-949-4975
  • Fax: 616-954-1795

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: NICOLE LYNN MAAG
Title or Position: CHIEF RESIDENTIAL OFFICER
Credential:
Phone: 616-460-9441