Provider Demographics
NPI:1477537397
Name:VISTA GRANDE VILLA
Entity Type:Organization
Organization Name:VISTA GRANDE VILLA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MS
Authorized Official - First Name:ELLEN
Authorized Official - Middle Name:A
Authorized Official - Last Name:KEATLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-787-0222
Mailing Address - Street 1:2251 SPRINGPORT RD
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49202-1496
Mailing Address - Country:US
Mailing Address - Phone:517-787-0222
Mailing Address - Fax:517-787-6909
Practice Address - Street 1:2251 SPRINGPORT RD
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49202-1496
Practice Address - Country:US
Practice Address - Phone:517-787-0222
Practice Address - Fax:517-787-6909
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-05
Last Update Date:2011-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI384210314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI09716OtherBLUE CROSS BLUE SH. OF MI
MI2081106Medicaid
MI09716OtherBLUE CROSS BLUE SH. OF MI