Provider Demographics
NPI:1558609974
Name:SUPERIOR HEALTH SUPPORT SYSTEM
Entity Type:Organization
Organization Name:SUPERIOR HEALTH SUPPORT SYSTEM
Other - Org Name:HEARTHSIDE ASSISTED LIVING
Other - Org Type:Doing Business As
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:JACLYN
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:CARNAHAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-635-6911
Mailing Address - Street 1:1501 W 6TH AVE
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1496
Mailing Address - Country:US
Mailing Address - Phone:906-635-6911
Mailing Address - Fax:906-635-8399
Practice Address - Street 1:1501 W 6TH AVE
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1496
Practice Address - Country:US
Practice Address - Phone:906-635-6911
Practice Address - Fax:906-635-8399
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-18
Last Update Date:2013-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI18002165740302R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302R00000XManaged Care OrganizationsHealth Maintenance Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1308588Medicare PIN