Healthcare Provider Details

I. General information

NPI: 1477537397
Provider Name (Legal Business Name): VISTA GRANDE VILLA
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/05/2005
Last Update Date: 11/29/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2251 SPRINGPORT RD
JACKSON MI
49202-1496
US

IV. Provider business mailing address

2251 SPRINGPORT RD
JACKSON MI
49202-1496
US

V. Phone/Fax

Practice location:
  • Phone: 517-787-0222
  • Fax: 517-787-6909
Mailing address:
  • Phone: 517-787-0222
  • Fax: 517-787-6909

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number384210
License Number StateMI

VIII. Authorized Official

Name: MS. ELLEN A. KEATLEY
Title or Position: PRESIDENT
Credential:
Phone: 517-787-0222