Provider Demographics
NPI:1578177994
Name:WTC SUB LLC
Entity Type:Organization
Organization Name:WTC SUB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING MEMBER
Authorized Official - Prefix:MR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:A
Authorized Official - Last Name:BECKETT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:630-364-0208
Mailing Address - Street 1:509 SHIP ST
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-1118
Mailing Address - Country:US
Mailing Address - Phone:269-983-2513
Mailing Address - Fax:
Practice Address - Street 1:509 SHIP ST
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-1118
Practice Address - Country:US
Practice Address - Phone:269-983-2513
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:WHITCOMB HOLDINGS LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2020-09-02
Last Update Date:2020-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility