MEDICARE: ATRIUM SOUTH HAVEN 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	80-4030	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	09947	OTHER	MI	BCBS PROVIDER CODE

General Provider Information

NPI Number	:	1689672792
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ATRIUM SOUTH HAVEN LLC

Provider Business Mailing Address
First Line	:	850 PHILLIPS ST
Second Line	:
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090-1845
Country	:	US
Telephone Number	:	269-637-5147
Fax Number	:	269-637-4943

Provider Business Practice Location Address
First Line	:	850 PHILLIPS ST
Second Line	:
City	:	SOUTH HAVEN
State	:	MI
Zip	:	49090-1845
Country	:	US
Telephone Number	:	269-637-5147
Fax Number	:	269-637-4943

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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