Provider Demographics
NPI:1356740245
Name:CROCKERY CREEK ELDER CARE, INC
Entity type:Organization
Organization Name:CROCKERY CREEK ELDER CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER - PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:GARY
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:MARSMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-206-2265
Mailing Address - Street 1:12291 CROCKERY CREEK DR
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:MI
Mailing Address - Zip Code:49451-8831
Mailing Address - Country:US
Mailing Address - Phone:231-853-8452
Mailing Address - Fax:231-853-8492
Practice Address - Street 1:12291 CROCKERY CREEK DR.
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:MI
Practice Address - Zip Code:49451
Practice Address - Country:US
Practice Address - Phone:231-853-8452
Practice Address - Fax:231-853-8492
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-08-18
Last Update Date:2014-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF610238757310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility