Provider Demographics
NPI:1073550885
Name:PINE RIVER HEALTHCARE LLC
Entity Type:Organization
Organization Name:PINE RIVER HEALTHCARE LLC
Other - Org Name:PINE RIVER HEALTHCARE CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JANET
Authorized Official - Middle Name:L
Authorized Official - Last Name:BAKER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-681-3852
Mailing Address - Street 1:1149 W MONROE RD
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MI
Mailing Address - Zip Code:48880-9736
Mailing Address - Country:US
Mailing Address - Phone:989-681-3852
Mailing Address - Fax:989-681-3856
Practice Address - Street 1:1149 W MONROE RD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MI
Practice Address - Zip Code:48880-9736
Practice Address - Country:US
Practice Address - Phone:989-681-3852
Practice Address - Fax:989-681-3856
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-01
Last Update Date:2016-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI294020314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4639839Medicaid
235324Medicare Oscar/Certification