Provider Demographics
NPI:1255040515
Name:EXTENDED CARE AT FREMONT, LLC
Entity type:Organization
Organization Name:EXTENDED CARE AT FREMONT, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:STEVEN
Authorized Official - Middle Name:
Authorized Official - Last Name:GERDEMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-494-4008
Mailing Address - Street 1:747 TAMARACK AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-4348
Mailing Address - Country:US
Mailing Address - Phone:194-944-0084
Mailing Address - Fax:616-317-1112
Practice Address - Street 1:54 FREMONT ST
Practice Address - Street 2:
Practice Address - City:BATTLE CREEK
Practice Address - State:MI
Practice Address - Zip Code:49017-3831
Practice Address - Country:US
Practice Address - Phone:419-494-4008
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home