Provider Demographics
NPI:1619162617
Name:SPECTRUM HEALTH KELSEY
Entity Type:Organization
Organization Name:SPECTRUM HEALTH KELSEY
Other - Org Name:SPECTRUM HEALTH REHAB & NURSING CENTERS - KELSEY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP FINANCE
Authorized Official - Prefix:MR
Authorized Official - First Name:RYAN
Authorized Official - Middle Name:K
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-225-6310
Mailing Address - Street 1:418 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48850-9806
Mailing Address - Country:US
Mailing Address - Phone:989-352-7211
Mailing Address - Fax:
Practice Address - Street 1:418 WASHINGTON ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:MI
Practice Address - Zip Code:48850-9806
Practice Address - Country:US
Practice Address - Phone:989-352-7211
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-09-12
Last Update Date:2014-06-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
313M00000X
MI593020314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No313M00000XNursing & Custodial Care FacilitiesNursing Facility/Intermediate Care Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI622000387Medicaid
MI09605OtherBLUE CROSS BLUE SHIELD
MI09605OtherBLUE CROSS BLUE SHIELD