Provider Demographics
NPI:1053636167
Name:GRACE HAVEN ASSISTED LIVING LLC
Entity Type:Organization
Organization Name:GRACE HAVEN ASSISTED LIVING LLC
Other - Org Name:GRACE HAVEN ASSISTED LIVING - LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NOBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-224-1650
Mailing Address - Street 1:1507 GLASTONBURY DR
Mailing Address - Street 2:
Mailing Address - City:SAINT JOHNS
Mailing Address - State:MI
Mailing Address - Zip Code:48879-8235
Mailing Address - Country:US
Mailing Address - Phone:989-224-1650
Mailing Address - Fax:
Practice Address - Street 1:1507 GLASTONBURY DR
Practice Address - Street 2:
Practice Address - City:SAINT JOHNS
Practice Address - State:MI
Practice Address - Zip Code:48879-8235
Practice Address - Country:US
Practice Address - Phone:989-224-1650
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-31
Last Update Date:2011-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D1102195291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory