Healthcare Provider Details

I. General information

NPI: 1326124322
Provider Name (Legal Business Name): COUNTY OF GRAND TRAVERSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/31/2006
Last Update Date: 11/14/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 PAVILIONS CIRCLE
TRAVERSE CITY MI
49684-3198
US

IV. Provider business mailing address

1000 PAVILIONS CIRCLE
TRAVERSE CITY MI
49684-3198
US

V. Phone/Fax

Practice location:
  • Phone: 231-932-3000
  • Fax: 231-932-3009
Mailing address:
  • Phone: 231-932-3000
  • Fax: 231-932-3009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number288510
License Number StateMI

VIII. Authorized Official

Name: MR. KORVYN R HANSEN JR.
Title or Position: CEO/ADMINISTRATOR
Credential:
Phone: 231-932-3010