Provider Demographics
NPI:1477933455
Name:PETOSKEY OPCO, LLC
Entity Type:Organization
Organization Name:PETOSKEY OPCO, LLC
Other - Org Name:THE VILLA AT THE BAY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BEN
Authorized Official - Middle Name:
Authorized Official - Last Name:ISRAEL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:847-440-2660
Mailing Address - Street 1:3755 CHASE AVE
Mailing Address - Street 2:
Mailing Address - City:SKOKIE
Mailing Address - State:IL
Mailing Address - Zip Code:60076-4008
Mailing Address - Country:US
Mailing Address - Phone:847-440-2660
Mailing Address - Fax:
Practice Address - Street 1:1500 SPRING ST
Practice Address - Street 2:
Practice Address - City:PETOSKEY
Practice Address - State:MI
Practice Address - Zip Code:49770-9295
Practice Address - Country:US
Practice Address - Phone:231-347-5500
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-06-04
Last Update Date:2021-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1477933455Medicaid
MI235429Medicare Oscar/Certification