Provider Demographics
NPI:1518341221
Name:BEACON SPECIALIZED LIVING SERVICES INC
Entity Type:Organization
Organization Name:BEACON SPECIALIZED LIVING SERVICES INC
Other - Org Name:BEACON SPRINGS
Other - Org Type:Doing Business As
Authorized Official - Title/Position:BUSINESS MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:GERALD
Authorized Official - Middle Name:
Authorized Official - Last Name:WRIGHT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-427-8400
Mailing Address - Street 1:555 RAILROAD ST
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1464
Mailing Address - Country:US
Mailing Address - Phone:269-427-8400
Mailing Address - Fax:
Practice Address - Street 1:6418 DEANS HILL RD
Practice Address - Street 2:STE 2
Practice Address - City:BERRIEN CENTER
Practice Address - State:MI
Practice Address - Zip Code:49102-9750
Practice Address - Country:US
Practice Address - Phone:269-427-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON SPECIALIZED LIVING SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-07-13
Last Update Date:2015-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL110366290320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAL110366290OtherLICENSE