Provider Demographics
NPI:1003802596
Name:MERCY MEMORIAL HEALTH SERVICES INC
Entity Type:Organization
Organization Name:MERCY MEMORIAL HEALTH SERVICES INC
Other - Org Name:PINE RIDGE: A REHABILITATION & NURSING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:
Authorized Official - First Name:MATTHEW
Authorized Official - Middle Name:E
Authorized Official - Last Name:COX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-391-1663
Mailing Address - Street 1:PO BOX 410
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-0410
Mailing Address - Country:US
Mailing Address - Phone:269-983-6501
Mailing Address - Fax:269-983-2237
Practice Address - Street 1:4368 CLEVELAND AVE
Practice Address - Street 2:
Practice Address - City:STEVENSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49127-9595
Practice Address - Country:US
Practice Address - Phone:269-983-6501
Practice Address - Fax:269-983-2237
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-21
Last Update Date:2023-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI114130314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2783575Medicaid
MI2783575Medicaid