Provider Demographics
NPI:1972802908
Name:GRAND TRAVERSE PAVILIONS HOME HEALTHCARE
Entity Type:Organization
Organization Name:GRAND TRAVERSE PAVILIONS HOME HEALTHCARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:KORVYN
Authorized Official - Middle Name:R
Authorized Official - Last Name:HANSEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-932-3021
Mailing Address - Street 1:1000 PAVILLIONS CIR
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-3198
Mailing Address - Country:US
Mailing Address - Phone:231-932-3000
Mailing Address - Fax:
Practice Address - Street 1:1000 PAVILLIONS CIR
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-3198
Practice Address - Country:US
Practice Address - Phone:231-932-3000
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:GRAND TRAVERSE PAVILIONS
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2011-03-16
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health