=====================================================
General NPI Number Information
=====================================================
NPI Number | 1417383845
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | EASTSIDE MANOR
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/17/2013
-----------------------------------------------------
Last Update Date | 09/18/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1439 EAST ST
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49442-5424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-773-2569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1439 EAST ST
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49442-5424
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-773-2569
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER
-----------------------------------------------------
Name | MR. JAMES FREDRICK MCEACHEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-773-2569
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 310400000X
-----------------------------------------------------
Taxonomy Name | Assisted Living Facility
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------