Healthcare Provider Details

I. General information

NPI: 1669553574
Provider Name (Legal Business Name): THE GRAND HOME OF MARSHALL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/18/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

111 N GRAND ST
MARSHALL MI
49068-1503
US

IV. Provider business mailing address

111 N GRAND ST
MARSHALL MI
49068-1503
US

V. Phone/Fax

Practice location:
  • Phone: 269-789-1111
  • Fax: 269-789-1212
Mailing address:
  • Phone: 269-789-1111
  • Fax: 269-789-1212

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License Number4704175126
License Number StateMI

VIII. Authorized Official

Name: MRS. REBECCA ANN SCHOOK
Title or Position: ADMINISTRATOR
Credential: REGISTERED NURSE
Phone: 269-789-1111