Provider Demographics
NPI:1629381868
Name:INDIAN TRAILS CAMP, INC.
Entity Type:Organization
Organization Name:INDIAN TRAILS CAMP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:TIM
Authorized Official - Middle Name:
Authorized Official - Last Name:HILEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-677-5251
Mailing Address - Street 1:O-1859 LAKE MICHIGAN DR NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49534-9578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:O-1859 LAKE MICHIGAN DR NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-9578
Practice Address - Country:US
Practice Address - Phone:616-677-5251
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-16
Last Update Date:2010-07-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MICR700200614385HR2050X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2050XRespite Care FacilityRespite CareRespite Care Camp