Provider Demographics
NPI:1801828835
Name:RESTHAVEN
Entity Type:Organization
Organization Name:RESTHAVEN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:DEEDRE
Authorized Official - Middle Name:
Authorized Official - Last Name:VRIESMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-796-3503
Mailing Address - Street 1:948 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49423-5205
Mailing Address - Country:US
Mailing Address - Phone:616-796-3500
Mailing Address - Fax:616-796-3508
Practice Address - Street 1:49 E 32ND ST
Practice Address - Street 2:
Practice Address - City:HOLLAND
Practice Address - State:MI
Practice Address - Zip Code:49423
Practice Address - Country:US
Practice Address - Phone:616-796-3700
Practice Address - Fax:616-796-3494
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:RESTHAVEN
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-07-07
Last Update Date:2018-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAH700236875310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0728304Medicaid