Healthcare Provider Details

I. General information

NPI: 1295208882
Provider Name (Legal Business Name): GRACEWAY SOUTH HAVEN, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/07/2019
Last Update Date: 01/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BASELINE RD
SOUTH HAVEN MI
49090-1037
US

IV. Provider business mailing address

1001 WOODWARD AVE FL 5
DETROIT MI
48226-1904
US

V. Phone/Fax

Practice location:
  • Phone: 269-637-8411
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY FISCHER
Title or Position: CEO
Credential:
Phone: 734-624-4887