Provider Demographics
NPI:1942689708
Name:THE SHORELINE CENTER LLC
Entity Type:Organization
Organization Name:THE SHORELINE CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RADLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-935-7606
Mailing Address - Street 1:16925 ABILITY WAY
Mailing Address - Street 2:
Mailing Address - City:GRAND HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49417-9325
Mailing Address - Country:US
Mailing Address - Phone:616-935-7606
Mailing Address - Fax:
Practice Address - Street 1:16925 ABILITY WAY
Practice Address - Street 2:
Practice Address - City:GRAND HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49417-9325
Practice Address - Country:US
Practice Address - Phone:616-935-7606
Practice Address - Fax:616-935-7607
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-27
Last Update Date:2021-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI6301014390103TC0700X
261QD1600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty
No261QD1600XAmbulatory Health Care FacilitiesClinic/CenterDevelopmental DisabilitiesGroup - Multi-Specialty