Provider Demographics
NPI:1467829028
Name:BUSH CREEK MANOR
Entity Type:Organization
Organization Name:BUSH CREEK MANOR
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/ADMINISTRATOR
Authorized Official - Prefix:MS
Authorized Official - First Name:WENDY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:BUSHARD
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:231-893-0322
Mailing Address - Street 1:1023 ALICE ST
Mailing Address - Street 2:
Mailing Address - City:WHITEHALL
Mailing Address - State:MI
Mailing Address - Zip Code:49461-1421
Mailing Address - Country:US
Mailing Address - Phone:231-893-0322
Mailing Address - Fax:
Practice Address - Street 1:1023 ALICE ST
Practice Address - Street 2:
Practice Address - City:WHITEHALL
Practice Address - State:MI
Practice Address - Zip Code:49461-1421
Practice Address - Country:US
Practice Address - Phone:231-893-0322
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-08-28
Last Update Date:2015-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIA610073721310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility