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General NPI Number Information
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NPI Number | 1477537397
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Entity Type | Organization
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Legal Business Name | VISTA GRANDE VILLA
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Dates
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Enumeration Date | 12/05/2005
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Last Update Date | 11/29/2011
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Provider Practice Location Address
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Address Line | 2251 SPRINGPORT RD
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City | JACKSON
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State | MI
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Zip | 49202-1496
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Country | US
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Telephone | 517-787-0222
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Fax | 517-787-6909
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Provider Business Mailing Address
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Address Line | 2251 SPRINGPORT RD
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City | JACKSON
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State | MI
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Zip | 49202-1496
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Country | US
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Telephone | 517-787-0222
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Fax | 517-787-6909
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Authorized Official
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Title or Position | PRESIDENT
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Name | MS. ELLEN A. KEATLEY
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Credential |
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Telephone | 517-787-0222
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 314000000X
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Taxonomy Name | Skilled Nursing Facility
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License Number | 384210
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License Number State | MI
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