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General NPI Number Information
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NPI Number | 1699087502
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Entity Type | Organization
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Legal Business Name | PLEASANT LAKE LODGE INC.
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Dates
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Enumeration Date | 07/08/2010
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Last Update Date | 07/08/2010
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Provider Practice Location Address
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Address Line | 2085 S 33 1/2 RD
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City | CADILLAC
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State | MI
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Zip | 49601-8055
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Country | US
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Telephone | 231-775-5847
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Fax |
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Provider Business Mailing Address
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Address Line | 2085 S 33 1/2 RD
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City | CADILLAC
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State | MI
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Zip | 49601-8055
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Country | US
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Telephone | 231-775-5847
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Fax |
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Authorized Official
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Title or Position | CEO
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Name | MRS. JANINE TUCKER-KUMMER
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Credential |
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Telephone | 231-775-5847
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL830300832
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License Number State | MI
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