Provider Demographics
NPI:1639313174
Name:BRONSON LAKEVIEW HOSPITAL
Entity Type:Organization
Organization Name:BRONSON LAKEVIEW HOSPITAL
Other - Org Name:BRONSON LAKEVIEW HOSPITAL BEHAVIORAL HEALTH
Other - Org Type:Doing Business As
Authorized Official - Title/Position:SVP,CFO
Authorized Official - Prefix:
Authorized Official - First Name:REBECCA
Authorized Official - Middle Name:
Authorized Official - Last Name:EAST
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-341-6000
Mailing Address - Street 1:301 JOHN ST
Mailing Address - Street 2:BOX 42
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49007-5295
Mailing Address - Country:US
Mailing Address - Phone:269-341-7806
Mailing Address - Fax:
Practice Address - Street 1:404 HAZEN ST
Practice Address - Street 2:SUITE L3
Practice Address - City:PAW PAW
Practice Address - State:MI
Practice Address - Zip Code:49079-1040
Practice Address - Country:US
Practice Address - Phone:269-657-1595
Practice Address - Fax:269-657-1534
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BRONSON LAKEVIEW HOSPITAL
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2009-04-28
Last Update Date:2016-07-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinicalGroup - Multi-Specialty
No103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0H010630OtherBCBSM
MI0H06012Medicare PIN