=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235454356
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EVERGREEN TERRACE ASSISTED LIVING
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/31/2010
-----------------------------------------------------
Last Update Date | 03/17/2011
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 801 FULLER AVE
-----------------------------------------------------
City | BIG RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49307-2106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-527-1050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 801 FULLER AVE
-----------------------------------------------------
City | BIG RAPIDS
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49307-2106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-527-1050
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. THOMAS NOBEL
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-527-1050
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 291U00000X
-----------------------------------------------------
Taxonomy Name | Clinical Medical Laboratory
-----------------------------------------------------
License Number | 23D1102189
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------