Provider Demographics
NPI:1275511487
Name:BLUE WATER NURSING CENTER
Entity Type:Organization
Organization Name:BLUE WATER NURSING CENTER
Other - Org Name:EVANGELICAL HOME - PORT HURON
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:LAWRENCE
Authorized Official - Middle Name:G
Authorized Official - Last Name:PETROSKEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:313-836-3499
Mailing Address - Street 1:5635 LAKESHORE RD
Mailing Address - Street 2:
Mailing Address - City:FORT GRATIOT
Mailing Address - State:MI
Mailing Address - Zip Code:48059-2817
Mailing Address - Country:US
Mailing Address - Phone:810-385-7447
Mailing Address - Fax:810-385-7114
Practice Address - Street 1:5635 LAKESHORE RD
Practice Address - Street 2:
Practice Address - City:FORT GRATIOT
Practice Address - State:MI
Practice Address - Zip Code:48059-2817
Practice Address - Country:US
Practice Address - Phone:810-385-7447
Practice Address - Fax:810-385-7114
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-01-06
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI744060314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235421Medicare ID - Type UnspecifiedPROVIDER NUMBER