MEDICARE: HEATHER HILLS NURSING, 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		MI
2	314000000X	Skilled Nursing Facility

General Provider Information

NPI Number	:	1972848042
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	HEATHER HILLS NURSING, LLC

Provider Business Mailing Address
First Line	:	954 RIDGEBROOK RD STE 130
Second Line	:
City	:	SPARKS
State	:	MD
Zip	:	21152-9469
Country	:	US
Telephone Number	:	410-387-0155
Fax Number	:	502-213-9977

Provider Business Practice Location Address
First Line	:	1157 MEDICAL PARK DR SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49546-3686
Country	:	US
Telephone Number	:	616-949-7310
Fax Number	:	616-956-0973

Authorized Official
Title or Position	:	CEO
Name	:	BRETTON J BOLT
Credential	:
Telephone Number	:	301-991-1388

Provider Enumeration Date	:	11/30/2012
Last Update Date	:	07/21/2022

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