Provider Demographics
NPI:1407849656
Name:LAKEVIEW LUTHERAN MANOR
Entity Type:Organization
Organization Name:LAKEVIEW LUTHERAN MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:GOODRICH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-775-0101
Mailing Address - Street 1:460 PEARL ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2620
Mailing Address - Country:US
Mailing Address - Phone:231-775-0101
Mailing Address - Fax:231-775-1390
Practice Address - Street 1:460 PEARL ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2620
Practice Address - Country:US
Practice Address - Phone:231-775-0101
Practice Address - Fax:231-775-1390
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LUTHERAN SOCIAL SERVICES OF MICHIGAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-08-23
Last Update Date:2008-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI844020314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI09537OtherBCBS
MI1796149Medicaid
MI09537OtherBCBS