=====================================================
General NPI Number Information
=====================================================
NPI Number | 1255339354
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ATRIUM ROOSEVELT PARK LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/12/2005
-----------------------------------------------------
Last Update Date | 03/03/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1300 W BROADWAY AVE
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49441-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-755-2221
-----------------------------------------------------
Fax | 231-755-3142
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1300 W BROADWAY AVE
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49441-3530
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-755-2221
-----------------------------------------------------
Fax | 231-755-3142
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CHIEF ACCOUNTING OFFICER
-----------------------------------------------------
Name | DENNIS LOCKHART
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 614-416-0600
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 61-4080
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------