Provider Demographics
NPI:1457688145
Name:FOREST GLEN ASSISTED LIVING
Entity Type:Organization
Organization Name:FOREST GLEN ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:HANER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-782-5300
Mailing Address - Street 1:3196 KRAFT AVE SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2078
Mailing Address - Country:US
Mailing Address - Phone:616-464-1564
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:2009-11-17
Last Update Date:2015-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL40280138310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D1102204OtherCLIA