{
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"EIN": null,
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"IsOrgSubpart": "N",
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"OrgName": "COVENANT LIVING OF THE GREAT LAKES",
"LastName": null,
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"NamePrefix": null,
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"Credential": null,
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"OtherLastNameTypeCode": null,
"FirstLineMailingAddress": "2520 LAKE MICHIGAN DRIVE NW",
"SecondLineMailingAddress": null,
"MailingAddressCityName": "GRAND RAPIDS",
"MailingAddressStateName": "MI",
"MailingAddressPostalCode": "49504-4696",
"MailingAddressCountryCode": "US",
"MailingAddressTelephoneNumber": "616-735-4541",
"MailingAddressFaxNumber": "616-735-5900",
"FirstLinePracticeLocationAddress": "2520 LAKE MICHIGAN DRIVE NW",
"SecondLinePracticeLocationAddress": null,
"PracticeLocationAddressCityName": "GRAND RAPIDS",
"PracticeLocationAddressStateName": "MI",
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"PracticeLocationAddressCountryCode": "US",
"PracticeLocationAddressTelephoneNumber": "616-735-4541",
"PracticeLocationAddressFaxNumber": "616-735-5900",
"EnumerationDate": "09/28/2006",
"LastUpdateDate": "01/28/2020",
"NPIDeactivationReasonCode": null,
"NPIDeactivationReason": null,
"NPIDeactivationDate": null,
"NPIReactivationDate": null,
"GenderCode": null,
"Gender": null,
"AuthorizedOfficialLastName": "MCLAREN",
"AuthorizedOfficialFirstName": "ELIZABETH",
"AuthorizedOfficialMiddleName": null,
"AuthorizedOfficialTitle": "ASSOCIATE VICE PRESIDENT OF HEALTH",
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"AuthorizedOfficialCredential": null,
"AuthorizedOfficialTelephoneNumber": "773-878-4430",
"Taxonomies": {
"Taxonomy": {
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"TaxonomyName": "Skilled Nursing Facility",
"LicenseNumber": "414382",
"LicenseNumberStateCode": "MI",
"PrimaryTaxonomySwitch": "Y"
}
},
"HealthcareProviderTaxonomyGroups": null
}
}