Provider Demographics
NPI:1437467255
Name:FOREST GLEN ASSISTED LIVING, LLC
Entity Type:Organization
Organization Name:FOREST GLEN ASSISTED LIVING, LLC
Other - Org Name:FOREST GLEN ASSISTED LIVING - LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:
Authorized Official - Last Name:NOBEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-782-5300
Mailing Address - Street 1:29601 AMERIHOST DR
Mailing Address - Street 2:
Mailing Address - City:DOWAGIAC
Mailing Address - State:MI
Mailing Address - Zip Code:49047-8320
Mailing Address - Country:US
Mailing Address - Phone:269-782-5300
Mailing Address - Fax:
Practice Address - Street 1:29601 AMERIHOST DR
Practice Address - Street 2:
Practice Address - City:DOWAGIAC
Practice Address - State:MI
Practice Address - Zip Code:49047-8320
Practice Address - Country:US
Practice Address - Phone:269-782-5300
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D1102204291U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory