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General NPI Number Information
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NPI Number | 1568554566
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Entity Type | Organization
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Legal Business Name | COVENANT LIVING OF THE GREAT LAKES
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Dates
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Enumeration Date | 09/28/2006
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Last Update Date | 01/28/2020
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Provider Practice Location Address
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Address Line | 2520 LAKE MICHIGAN DRIVE NW
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City | GRAND RAPIDS
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State | MI
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Zip | 49504-4696
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Country | US
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Telephone | 616-735-4541
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Fax | 616-735-5900
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Provider Business Mailing Address
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Address Line | 2520 LAKE MICHIGAN DRIVE NW
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City | GRAND RAPIDS
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State | MI
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Zip | 49504-4696
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Country | US
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Telephone | 616-735-4541
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Fax | 616-735-5900
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Authorized Official
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Title or Position | ASSOCIATE VICE PRESIDENT OF HEALTH
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Name | ELIZABETH MCLAREN
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Credential |
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Telephone | 773-878-4430
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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 | 414382
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License Number State | MI
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