Healthcare Provider Details

I. General information

NPI: 1730514290
Provider Name (Legal Business Name): PINE RIDGE ADULT CARE HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/03/2013
Last Update Date: 09/03/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15467 PORT SHELDON ST
WEST OLIVE MI
49460-9715
US

IV. Provider business mailing address

15467 PORT SHELDON ST
WEST OLIVE MI
49460-9715
US

V. Phone/Fax

Practice location:
  • Phone: 616-399-1774
  • Fax: 616-738-0009
Mailing address:
  • Phone: 616-399-1774
  • Fax: 616-738-0009

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License NumberAL700079149
License Number StateMI

VIII. Authorized Official

Name: MRS. DEBRA ANN WESTERHOF I
Title or Position: LICENSEE
Credential:
Phone: 616-399-1774