=====================================================
General NPI Number Information
=====================================================
NPI Number | 1679514970
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HEARTLAND-KNOLLVIEW MI LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2006
-----------------------------------------------------
Last Update Date | 05/23/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1061 W HACKLEY AVE
-----------------------------------------------------
City | MUSKEGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49441-3059
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-755-2255
-----------------------------------------------------
Fax | 231-759-7612
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 333 N SUMMIT ST
-----------------------------------------------------
City | TOLEDO
-----------------------------------------------------
State | OH
-----------------------------------------------------
Zip | 43604-2615
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 419-252-5500
-----------------------------------------------------
Fax | 877-385-9446
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR
-----------------------------------------------------
Name | MR. MARTIN D ALLEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 419-252-5734
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 314000000X
-----------------------------------------------------
Taxonomy Name | Skilled Nursing Facility
-----------------------------------------------------
License Number | 614050
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------