Provider Demographics
NPI:1508962069
Name:CHARLEVOIX NURSING HOME CORPORATION
Entity Type:Organization
Organization Name:CHARLEVOIX NURSING HOME CORPORATION
Other - Org Name:BOULDER PARK TERRACE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:BELLAMY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-487-4094
Mailing Address - Street 1:14676 W UPRIGHT ST
Mailing Address - Street 2:
Mailing Address - City:CHARLEVOIX
Mailing Address - State:MI
Mailing Address - Zip Code:49720-1201
Mailing Address - Country:US
Mailing Address - Phone:231-547-1005
Mailing Address - Fax:
Practice Address - Street 1:14676 W UPRIGHT ST
Practice Address - Street 2:
Practice Address - City:CHARLEVOIX
Practice Address - State:MI
Practice Address - Zip Code:49720-1201
Practice Address - Country:US
Practice Address - Phone:231-547-1005
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-15
Last Update Date:2017-08-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI235526313M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2896882Medicaid
MI235526Medicare Oscar/Certification