Provider Demographics
NPI:1538101977
Name:PENNOCK HOSPITAL
Entity Type:Organization
Organization Name:PENNOCK HOSPITAL
Other - Org Name:PENNOCK HOMECARE SERVICES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:SHERYL
Authorized Official - Middle Name:L
Authorized Official - Last Name:LEWIS-BLAKE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-948-3123
Mailing Address - Street 1:1009 W GREEN ST
Mailing Address - Street 2:
Mailing Address - City:HASTINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49058-1710
Mailing Address - Country:US
Mailing Address - Phone:269-945-1212
Mailing Address - Fax:269-948-3117
Practice Address - Street 1:1009 W GREEN ST
Practice Address - Street 2:
Practice Address - City:HASTINGS
Practice Address - State:MI
Practice Address - Zip Code:49058-1710
Practice Address - Country:US
Practice Address - Phone:269-945-1212
Practice Address - Fax:269-948-3117
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2016-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3332247Medicaid
MIOE155OtherBCBS PROVIDER NUMBER
MI237415Medicare Oscar/Certification