Provider Demographics
NPI:1972557460
Name:HOLLAND HOME
Entity Type:Organization
Organization Name:HOLLAND HOME
Other - Org Name:HOLLAND HOME - FULTON MANOR
Other - Org Type:Other Name
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TIESENGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-235-5035
Mailing Address - Street 1:1450 EAST FULTON
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-3854
Mailing Address - Country:US
Mailing Address - Phone:616-643-2600
Mailing Address - Fax:616-643-2623
Practice Address - Street 1:1450 EAST FULTON
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-3854
Practice Address - Country:US
Practice Address - Phone:616-643-2600
Practice Address - Fax:616-643-2623
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLLAND HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-20
Last Update Date:2016-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14196314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2081311Medicaid
09887OtherBCBS OF MICHIGAN
235435Medicare Oscar/Certification