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General NPI Number Information
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NPI Number | 1487066734
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Entity Type | Organization
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Legal Business Name | GREAT LIVING FOSTER CARE
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Dates
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Enumeration Date | 05/21/2014
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Last Update Date | 05/21/2014
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Provider Practice Location Address
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Address Line | 8973 PIONEER CT
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City | BERRIEN SPRINGS
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State | MI
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Zip | 49103-1700
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Country | US
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Telephone | 269-815-2087
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Fax | 269-815-5064
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Provider Business Mailing Address
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Address Line | 8973 PIONEER CT
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City | BERRIEN SPRINGS
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State | MI
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Zip | 49103-1700
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Country | US
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Telephone | 269-815-2087
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Fax | 269-815-5064
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Authorized Official
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Title or Position | MANAGER
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Name | BERGELINE FLORVILUS
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Credential | RN
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Telephone | 269-815-2087
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 320800000X
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Taxonomy Name | Mental Illness Community Based Residential Treatment Facility
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License Number | AF110317417
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License Number State | MI
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