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General NPI Number Information
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NPI Number | 1750718078
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Entity Type | Organization
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Legal Business Name | WILDS RIVER REST
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Dates
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Enumeration Date | 10/01/2013
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Last Update Date | 10/01/2013
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Provider Practice Location Address
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Address Line | 12409 N RED BUD TRL
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City | BUCHANAN
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State | MI
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Zip | 49107-9139
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Country | US
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Telephone | 269-695-6074
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Fax | 269-697-0474
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Provider Business Mailing Address
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Address Line | 12409 N RED BUD TRL
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City | BUCHANAN
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State | MI
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Zip | 49107-9139
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Country | US
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Telephone | 269-695-6074
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Fax | 269-697-0474
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Authorized Official
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Title or Position | OWNER
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Name | MS. JANICE ELLEN WILDS
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Credential |
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Telephone | 269-695-6074
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311Z00000X
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Taxonomy Name | Custodial Care Facility
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License Number | AM110064771
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AM110064771
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License Number State | MI
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