Provider Demographics
NPI:1568554566
Name:COVENANT LIVING OF THE GREAT LAKES
Entity Type:Organization
Organization Name:COVENANT LIVING OF THE GREAT LAKES
Other - Org Name:COVENANT LIVING OF THE GREAT LAKES
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ASSOCIATE VICE PRESIDENT OF HEALTH
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:MCLAREN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:773-878-4430
Mailing Address - Street 1:2520 LAKE MICHIGAN DRIVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4696
Mailing Address - Country:US
Mailing Address - Phone:616-735-4541
Mailing Address - Fax:616-735-5900
Practice Address - Street 1:2520 LAKE MICHIGAN DRIVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-4696
Practice Address - Country:US
Practice Address - Phone:616-735-4541
Practice Address - Fax:616-735-5900
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-09-28
Last Update Date:2020-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI414382314000000X, 314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI7974902Medicaid
MIF27390Medicare UPIN
MI235614Medicare Oscar/Certification