Provider Demographics
NPI:1114351152
Name:CRESTWOOD VILLAGE ASSISTED LIVING
Entity Type:Organization
Organization Name:CRESTWOOD VILLAGE ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MS
Authorized Official - First Name:SAMANTHA
Authorized Official - Middle Name:
Authorized Official - Last Name:THELEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-881-6051
Mailing Address - Street 1:3196 KRAFT AVE SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2078
Mailing Address - Country:US
Mailing Address - Phone:616-464-1564
Mailing Address - Fax:616-464-2470
Practice Address - Street 1:2378 SOUTH LINCOLN RD
Practice Address - Street 2:
Practice Address - City:MT. PLEASANT
Practice Address - State:MI
Practice Address - Zip Code:48858
Practice Address - Country:US
Practice Address - Phone:989-772-2183
Practice Address - Fax:989-772-2296
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEISURE LIVING MANAGEMENT
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2013-08-27
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAH370325563302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization