Provider Demographics
NPI:1154657591
Name:BARUCH SLS, INC.
Entity Type:Organization
Organization Name:BARUCH SLS, INC.
Other - Org Name:FOUNTAIN VIEW ASSISTED LIVING - LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLAUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-285-0573
Mailing Address - Street 1:3196 KRAFT AVE SE STE 203
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2065
Mailing Address - Country:US
Mailing Address - Phone:616-285-0573
Mailing Address - Fax:
Practice Address - Street 1:640 W RANDALL ST
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1306
Practice Address - Country:US
Practice Address - Phone:616-997-9253
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-10-20
Last Update Date:2023-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D0975401291U00000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D0975401OtherCLIA