Healthcare Provider Details

I. General information

NPI: 1417398595
Provider Name (Legal Business Name): SPRING LAKE COMPASSIONATE LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/17/2013
Last Update Date: 07/18/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16609 VILLA PKWY
SPRING LAKE MI
49456-8835
US

IV. Provider business mailing address

16609 VILLA PKWY
SPRING LAKE MI
49456-8835
US

V. Phone/Fax

Practice location:
  • Phone: 616-414-5006
  • Fax:
Mailing address:
  • Phone: 616-414-5006
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAS700321868
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License NumberAS700321868
License Number StateMI

VIII. Authorized Official

Name: MR. DANIEL JAY MODDERMAN
Title or Position: DESIGNEE
Credential:
Phone: 616-334-6262