MEDICARE: ATRIUM ROOSEVELT PARK LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	314000000X	Skilled Nursing Facility	61-4080	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	09692	OTHER	MI	BCBS PROVIDER CODE

General Provider Information

NPI Number	:	1255339354
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATRIUM ROOSEVELT PARK LLC

Provider Business Mailing Address
First Line	:	1300 W BROADWAY AVE
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-3530
Country	:	US
Telephone Number	:	231-755-2221
Fax Number	:	231-755-3142

Provider Business Practice Location Address
First Line	:	1300 W BROADWAY AVE
Second Line	:
City	:	MUSKEGON
State	:	MI
Zip	:	49441-3530
Country	:	US
Telephone Number	:	231-755-2221
Fax Number	:	231-755-3142

Authorized Official
Title or Position	:	CHIEF ACCOUNTING OFFICER
Name	:	DENNIS LOCKHART
Credential	:
Telephone Number	:	614-416-0600

Provider Enumeration Date	:	07/12/2005
Last Update Date	:	03/03/2025

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