Provider Demographics
NPI:1285651760
Name:LAKELAND SPECIALTY HOSPITAL AT BERRIEN CENTER
Entity Type:Organization
Organization Name:LAKELAND SPECIALTY HOSPITAL AT BERRIEN CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO/VP OF FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:CALHOUN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-983-8398
Mailing Address - Street 1:PO BOX 800
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-0800
Mailing Address - Country:US
Mailing Address - Phone:269-428-2574
Mailing Address - Fax:269-428-0490
Practice Address - Street 1:6418 DEANS HILL RD
Practice Address - Street 2:
Practice Address - City:BERRIEN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49102-9750
Practice Address - Country:US
Practice Address - Phone:269-473-3003
Practice Address - Fax:269-473-3010
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-17
Last Update Date:2008-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI113010314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4164932Medicaid
S9516OtherBLUE CROSS
S9516OtherBLUE CROSS