Provider Demographics
NPI:1265421051
Name:CLARK RETIREMENT COMMUNITY, INC.
Entity type:Organization
Organization Name:CLARK RETIREMENT COMMUNITY, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRIAN
Authorized Official - Middle Name:A
Authorized Official - Last Name:PANGLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-452-1568
Mailing Address - Street 1:1551 FRANKLIN ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506
Mailing Address - Country:US
Mailing Address - Phone:616-452-1568
Mailing Address - Fax:616-247-9625
Practice Address - Street 1:1551 FRANKLIN ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506
Practice Address - Country:US
Practice Address - Phone:616-452-1568
Practice Address - Fax:616-247-9625
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-10-14
Last Update Date:2015-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI235401314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2081269Medicaid
MI2081269Medicaid