Provider Demographics
NPI:1417398595
Name:SPRING LAKE COMPASSIONATE LIVING
Entity Type:Organization
Organization Name:SPRING LAKE COMPASSIONATE LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DESIGNEE
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:JAY
Authorized Official - Last Name:MODDERMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-334-6262
Mailing Address - Street 1:16609 VILLA PKWY
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:49456-8835
Mailing Address - Country:US
Mailing Address - Phone:616-414-5006
Mailing Address - Fax:
Practice Address - Street 1:16609 VILLA PKWY
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:MI
Practice Address - Zip Code:49456-8835
Practice Address - Country:US
Practice Address - Phone:616-414-5006
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-07-17
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS700321868310400000X, 320700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No320700000XResidential Treatment FacilitiesResidential Treatment Facility, Physical Disabilities