Healthcare Provider Details

I. General information

NPI: 1124065016
Provider Name (Legal Business Name): LIFE CARE CENTERS OF AMERICA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 09/15/2021
Certification Date: 09/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

320 BRIGHAM ST
PLAINWELL MI
49080-1577
US

IV. Provider business mailing address

3001 KEITH ST NW
CLEVELAND TN
37312-3713
US

V. Phone/Fax

Practice location:
  • Phone: 616-685-9805
  • Fax: 616-685-8542
Mailing address:
  • Phone: 423-473-5751
  • Fax: 423-339-8342

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number34020
License Number StateMI

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier602781786
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer

VIII. Authorized Official

Name: CINDY S CROSS
Title or Position: ASSISTANT SECRETARY
Credential:
Phone: 423-473-5867