Provider Demographics
NPI:1003068982
Name:REST HAVEN ILLIANA CHRISTIAN CONVELESCENT HOME
Entity Type:Organization
Organization Name:REST HAVEN ILLIANA CHRISTIAN CONVELESCENT HOME
Other - Org Name:PROVIDENCE AT HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JONATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:708-342-8126
Mailing Address - Street 1:500 PARKSIDE DR
Mailing Address - Street 2:SUITE 159
Mailing Address - City:ZEELAND
Mailing Address - State:MI
Mailing Address - Zip Code:49464-2056
Mailing Address - Country:US
Mailing Address - Phone:616-772-2935
Mailing Address - Fax:616-772-9998
Practice Address - Street 1:500 PARKSIDE DR
Practice Address - Street 2:SUITE 159
Practice Address - City:ZEELAND
Practice Address - State:MI
Practice Address - Zip Code:49464-2056
Practice Address - Country:US
Practice Address - Phone:616-772-2935
Practice Address - Fax:616-772-9998
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-10-22
Last Update Date:2008-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health