Provider Demographics
NPI:1467511907
Name:HYLAND CONVALESCENT HOME
Entity Type:Organization
Organization Name:HYLAND CONVALESCENT HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:L
Authorized Official - Last Name:REDDING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-774-9333
Mailing Address - Street 1:601 E G ST
Mailing Address - Street 2:
Mailing Address - City:IRON MOUNTAIN
Mailing Address - State:MI
Mailing Address - Zip Code:49801-4061
Mailing Address - Country:US
Mailing Address - Phone:906-774-9333
Mailing Address - Fax:
Practice Address - Street 1:601 E G ST
Practice Address - Street 2:
Practice Address - City:IRON MOUNTAIN
Practice Address - State:MI
Practice Address - Zip Code:49801-4061
Practice Address - Country:US
Practice Address - Phone:906-774-9333
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-08
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI22-404313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2080510Medicaid