Provider Demographics
NPI:1164852240
Name:TIMBERLINE LODGE INC. AFC
Entity Type:Organization
Organization Name:TIMBERLINE LODGE INC. AFC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DIEGEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-673-4990
Mailing Address - Street 1:3771 COLWOOD RD
Mailing Address - Street 2:
Mailing Address - City:CARO
Mailing Address - State:MI
Mailing Address - Zip Code:48723-9732
Mailing Address - Country:US
Mailing Address - Phone:989-673-4990
Mailing Address - Fax:989-673-4991
Practice Address - Street 1:3771 COLWOOD RD
Practice Address - Street 2:
Practice Address - City:CARO
Practice Address - State:MI
Practice Address - Zip Code:48723-9732
Practice Address - Country:US
Practice Address - Phone:989-673-4990
Practice Address - Fax:989-673-4991
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-26
Last Update Date:2013-11-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM790009691311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAM790009691OtherLICENSE NUMBER