Healthcare Provider Details

I. General information

NPI: 1073550885
Provider Name (Legal Business Name): PINE RIVER HEALTHCARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/01/2006
Last Update Date: 02/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1149 W MONROE RD
SAINT LOUIS MI
48880-9736
US

IV. Provider business mailing address

1149 W MONROE RD
SAINT LOUIS MI
48880-9736
US

V. Phone/Fax

Practice location:
  • Phone: 989-681-3852
  • Fax: 989-681-3856
Mailing address:
  • Phone: 989-681-3852
  • Fax: 989-681-3856

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number294020
License Number StateMI

VIII. Authorized Official

Name: JANET L. BAKER
Title or Position: MANAGER
Credential:
Phone: 989-681-3852