Provider Demographics
NPI:1508082876
Name:LEISURE LIVING MANAGEMENT OF BUCHANAN
Entity Type:Organization
Organization Name:LEISURE LIVING MANAGEMENT OF BUCHANAN
Other - Org Name:BUCHANAN MEADOWS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:MICHELLE
Authorized Official - Middle Name:
Authorized Official - Last Name:FIELDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-695-6655
Mailing Address - Street 1:809 CAROLL ST
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-1738
Mailing Address - Country:US
Mailing Address - Phone:269-695-6655
Mailing Address - Fax:269-695-6673
Practice Address - Street 1:809 CAROLL ST
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-1738
Practice Address - Country:US
Practice Address - Phone:269-695-6655
Practice Address - Fax:269-695-6673
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:LEISURE LIVING MANAGEMENT OF BUCHANAN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-04-17
Last Update Date:2008-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL110081160310400000X
MIAL110065097311500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311500000XNursing & Custodial Care FacilitiesAlzheimer Center (Dementia Center)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI=========OtherEIN