Provider Demographics
NPI:1710221478
Name:BARUCH SLS INC
Entity Type:Organization
Organization Name:BARUCH SLS INC
Other - Org Name:PARK PLACE ASSISTED LIVING - LABORATORY
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VP OPERATIONS
Authorized Official - Prefix:
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLAUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-285-0573
Mailing Address - Street 1:3196 KRAFT AVE SE STE 203
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2065
Mailing Address - Country:US
Mailing Address - Phone:616-285-0573
Mailing Address - Fax:
Practice Address - Street 1:4222 S WESTNEDGE AVE
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49008-3208
Practice Address - Country:US
Practice Address - Phone:269-388-7303
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BARUCH SLS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-11-19
Last Update Date:2020-09-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI23D2048518291U00000X
310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI23D2048518OtherCLIA