Provider Demographics
NPI:1205297249
Name:CHALET OF ADRIAN LLC
Entity type:Organization
Organization Name:CHALET OF ADRIAN LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MBR
Authorized Official - Prefix:
Authorized Official - First Name:JEFFREY
Authorized Official - Middle Name:
Authorized Official - Last Name:SAX
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:219-898-5705
Mailing Address - Street 1:6101 NIMTZ PKWY
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46628-6111
Mailing Address - Country:US
Mailing Address - Phone:219-898-5705
Mailing Address - Fax:
Practice Address - Street 1:130 SAND CREEK HWY
Practice Address - Street 2:
Practice Address - City:ADRIAN
Practice Address - State:MI
Practice Address - Zip Code:49221-9129
Practice Address - Country:US
Practice Address - Phone:219-898-5705
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-03-18
Last Update Date:2016-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI235504Medicare Oscar/Certification