Healthcare Provider Details

I. General information

NPI: 1790110070
Provider Name (Legal Business Name): BEACON SPECIALIZED LIVING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

628 E MAIN ST APT 8
SEBEWAING MI
48759-1698
US

IV. Provider business mailing address

628 E MAIN ST APT 8
SEBEWAING MI
48759-1698
US

V. Phone/Fax

Practice location:
  • Phone: 989-883-2600
  • Fax: 989-883-2601
Mailing address:
  • Phone: 989-883-2600
  • Fax: 989-883-2601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number4703095012
License Number StateMI

VIII. Authorized Official

Name: DONNA KAY MANARY
Title or Position: STAFF NURSE / HOUSE MANAGER
Credential: LPN
Phone: 989-883-2600