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NPI Code Detail

MEDICARE: SOUTH HAVEN OPCO, LLC

MEDICARE: SOUTH HAVEN OPCO, 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
1314000000XSkilled Nursing Facility

General Provider Information

NPI Number : 1649855917
Entity Type Code : Organization
Provider Name (Legal Business Name) : SOUTH HAVEN OPCO, LLC
Provider Business Mailing Address
First Line : 7400 NEW LA GRANGE RD STE 100
Second Line :
City : LOUISVILLE
State : KY
Zip : 40222-4870
Country : US
Telephone Number : 502-429-8062
Fax Number : 502-429-5980
Provider Business Practice Location Address
First Line : 120 BASELINE RD
Second Line :
City : SOUTH HAVEN
State : MI
Zip : 49090-1037
Country : US
Telephone Number : 269-637-8411
Fax Number :
Authorized Official
Title or Position : CHIEF LEGAL OFFICER
Name : JONATHAN OHLSEN
Credential : JD
Telephone Number : 541-543-1215
Provider Enumeration Date : 03/17/2021
Last Update Date : 03/17/2021

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Directions to “SOUTH HAVEN OPCO, LLC ” Practice Location

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