Provider Demographics
NPI:1073506473
Name:CHRISTIAN REST HOME ASSOCIATION
Entity Type:Organization
Organization Name:CHRISTIAN REST HOME ASSOCIATION
Other - Org Name:CHRISTIAN REST HOME
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CHIEF FINANCIAL OFFICER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HORJUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-453-2475
Mailing Address - Street 1:1000 EDISON AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3918
Mailing Address - Country:US
Mailing Address - Phone:616-453-2475
Mailing Address - Fax:616-453-2645
Practice Address - Street 1:1000 EDISON AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-3918
Practice Address - Country:US
Practice Address - Phone:616-453-2475
Practice Address - Fax:616-453-2645
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-08-31
Last Update Date:2008-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI414020314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI60/2151793Medicaid
235339Medicare Oscar/Certification
MI60/2151793Medicaid