Provider Demographics
NPI:1306828504
Name:BRONSON AT HOME
Entity Type:Organization
Organization Name:BRONSON AT HOME
Other - Org Name:LIFESPAN, INC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:VP, BRONSON AT HOME
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-6000
Mailing Address - Street 1:301 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5295
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:
Practice Address - Street 1:165 WASHINGTON AVE N
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49037-2929
Practice Address - Country:US
Practice Address - Phone:269-660-3600
Practice Address - Fax:269-660-3650
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-11-15
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251G00000XAgenciesHospice Care, Community Based
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3332443Medicaid
MI08767OtherBCBS
MI08767OtherBCBS