Provider Demographics
NPI:1639861297
Name:GHAC3 NILES MI ALF TRS SUB LLC
Entity Type:Organization
Organization Name:GHAC3 NILES MI ALF TRS SUB LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SR DIRECTO OF COMPLIANCE & REVENUE
Authorized Official - Prefix:
Authorized Official - First Name:TAMMY
Authorized Official - Middle Name:
Authorized Official - Last Name:GERARDOT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-414-5085
Mailing Address - Street 1:1102 CHESTNUT HILLS PKWY STE 100
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46814-8728
Mailing Address - Country:US
Mailing Address - Phone:260-414-5085
Mailing Address - Fax:
Practice Address - Street 1:1147 S 3RD ST
Practice Address - Street 2:
Practice Address - City:NILES
Practice Address - State:MI
Practice Address - Zip Code:49120-3472
Practice Address - Country:US
Practice Address - Phone:269-684-9470
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-23
Last Update Date:2023-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care