Provider Demographics
NPI:1972847184
Name:INDIAN TRAILS CAMP, INC.
Entity Type:Organization
Organization Name:INDIAN TRAILS CAMP, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TIMOTHY
Authorized Official - Middle Name:
Authorized Official - Last Name:HILEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-677-5251
Mailing Address - Street 1:PO BOX 97
Mailing Address - Street 2:
Mailing Address - City:GRANDVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:49468
Mailing Address - Country:US
Mailing Address - Phone:616-677-5251
Mailing Address - Fax:616-677-2955
Practice Address - Street 1:O-1859 LAKE MICHIGAN DR. NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534
Practice Address - Country:US
Practice Address - Phone:616-677-5251
Practice Address - Fax:616-677-2955
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-11-15
Last Update Date:2012-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251C00000X
MISR700200220385H00000X
MIAC700200613385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care
No251C00000XAgenciesDay Training, Developmentally Disabled Services