Healthcare Provider Details

I. General information

NPI: 1649855917
Provider Name (Legal Business Name): SOUTH HAVEN OPCO, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2021
Last Update Date: 03/17/2021
Certification Date: 03/17/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

120 BASELINE RD
SOUTH HAVEN MI
49090-1037
US

IV. Provider business mailing address

7400 NEW LA GRANGE RD STE 100
LOUISVILLE KY
40222-4870
US

V. Phone/Fax

Practice location:
  • Phone: 269-637-8411
  • Fax:
Mailing address:
  • Phone: 502-429-8062
  • Fax: 502-429-5980

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: JONATHAN OHLSEN
Title or Position: CHIEF LEGAL OFFICER
Credential: JD
Phone: 541-543-1215