Provider Demographics
NPI:1720196819
Name:FOUNTAIN VIEW RETIREMENT
Entity Type:Organization
Organization Name:FOUNTAIN VIEW RETIREMENT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/NURSE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:GRAFF
Authorized Official - Suffix:
Authorized Official - Credentials:LPN
Authorized Official - Phone:231-924-5050
Mailing Address - Street 1:102 HILLCREST DR
Mailing Address - Street 2:
Mailing Address - City:FREMONT
Mailing Address - State:MI
Mailing Address - Zip Code:49412-1348
Mailing Address - Country:US
Mailing Address - Phone:231-924-5050
Mailing Address - Fax:231-924-6445
Practice Address - Street 1:102 HILLCREST DR
Practice Address - Street 2:
Practice Address - City:FREMONT
Practice Address - State:MI
Practice Address - Zip Code:49412-1348
Practice Address - Country:US
Practice Address - Phone:231-924-5050
Practice Address - Fax:231-924-6445
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-08-28
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N27990Medicare UPIN