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General NPI Number Information
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NPI Number | 1982099586
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Entity Type | Organization
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Legal Business Name | SHANGRILA HOME
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Dates
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Enumeration Date | 03/31/2015
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Last Update Date | 03/31/2015
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Provider Practice Location Address
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Address Line | 8876 KEPHART LN
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City | BERRIEN SPRINGS
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State | MI
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Zip | 49103-1440
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Country | US
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Telephone | 269-473-7000
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Fax | 269-473-8876
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Provider Business Mailing Address
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Address Line | 8876 KEPHART LN
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City | BERRIEN SPRINGS
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State | MI
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Zip | 49103-1440
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Country | US
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Telephone | 269-473-7000
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Fax | 269-473-8876
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Authorized Official
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Title or Position | GENERAL MANAGER
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Name | DYAN A LEE
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Credential |
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Telephone | 269-473-7000
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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 | AF110000791
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License Number State | MI
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