Provider Demographics
NPI:1447216478
Name:COUNTY OF CHARLEVOIX
Entity Type:Organization
Organization Name:COUNTY OF CHARLEVOIX
Other - Org Name:GRANDVUE MEDICAL CARE FACILITY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MR
Authorized Official - First Name:KEVIN
Authorized Official - Middle Name:
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-536-2286
Mailing Address - Street 1:1728 S PENINSULA RD
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9410
Mailing Address - Country:US
Mailing Address - Phone:231-536-2286
Mailing Address - Fax:231-536-2476
Practice Address - Street 1:1728 S PENINSULA RD
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9410
Practice Address - Country:US
Practice Address - Phone:231-536-2286
Practice Address - Fax:231-536-2476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-04-26
Last Update Date:2008-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI158510314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2085179Medicaid
MI2085179Medicaid