Healthcare Provider Details

I. General information

NPI: 1326034000
Provider Name (Legal Business Name): HEARTWOOD LODGE TRINITY HEALTH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/27/2005
Last Update Date: 07/26/2023
Certification Date: 07/26/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18525 WOODLAND RIDGE DR
SPRING LAKE MI
49456-8876
US

IV. Provider business mailing address

18525 WOODLAND RIDGE DR
SPRING LAKE MI
49456-8876
US

V. Phone/Fax

Practice location:
  • Phone: 616-842-0770
  • Fax:
Mailing address:
  • Phone: 616-842-0770
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier1326034000
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 2
Identifier1675500-60
Identifier TypeMEDICAID
Identifier StateMI
Identifier Issuer
# 3
Identifier09854
Identifier TypeOTHER
Identifier StateMI
Identifier IssuerBLUE CROSS BLUE SHIELD

VIII. Authorized Official

Name: PAMELA SUE LATOVICK
Title or Position: VP REIMBURSEMENT
Credential:
Phone: 734-343-6628