Healthcare Provider Details

I. General information

NPI: 1891198057
Provider Name (Legal Business Name): PINECREST FARMS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/02/2014
Last Update Date: 10/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

413 N HOMER RD
MIDLAND MI
48640-8646
US

IV. Provider business mailing address

413 N HOMER RD
MIDLAND MI
48640-8646
US

V. Phone/Fax

Practice location:
  • Phone: 989-832-6634
  • Fax: 989-837-0666
Mailing address:
  • Phone: 989-832-6634
  • Fax: 989-837-0666

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberA1560000004
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License NumberA1560000004
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License NumberA1560000004
License Number StateMI

VIII. Authorized Official

Name: JOE BLEWETT
Title or Position: ADMINISTRATOR
Credential:
Phone: 989-832-6634