Provider Demographics
NPI:1124002910
Name:HAROLD AND GRACE UPJOHN COMMUNITY CARE CENTER
Entity Type:Organization
Organization Name:HAROLD AND GRACE UPJOHN COMMUNITY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANA
Authorized Official - Middle Name:
Authorized Official - Last Name:WHITE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-381-4290
Mailing Address - Street 1:2400 PORTAGE ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49001-3728
Mailing Address - Country:US
Mailing Address - Phone:269-381-4290
Mailing Address - Fax:269-343-5474
Practice Address - Street 1:2400 PORTAGE ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49001-3728
Practice Address - Country:US
Practice Address - Phone:269-381-4290
Practice Address - Fax:269-343-5474
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HERITAGE COMMUNITY OF KALAMAZOO
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-12-05
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI394090314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2081160Medicaid
MI09557OtherBC BS OF MI
MI=========OtherFEDERAL TAX ID #
MI2081160Medicaid