Provider Demographics
NPI:1396799987
Name:HOLLAND HOME
Entity type:Organization
Organization Name:HOLLAND HOME
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:ADAM
Authorized Official - Middle Name:
Authorized Official - Last Name:KINDER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-235-5015
Mailing Address - Street 1:2121 RAYBROOK ST SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5793
Mailing Address - Country:US
Mailing Address - Phone:616-235-5002
Mailing Address - Fax:616-235-5088
Practice Address - Street 1:2121 RAYBROOK ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5793
Practice Address - Country:US
Practice Address - Phone:616-235-5002
Practice Address - Fax:616-235-5088
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:HOLLAND HOME
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2006-05-19
Last Update Date:2021-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI14208314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2084260Medicaid
09891OtherBCBS OF MICHIGAN
09891OtherBCBS OF MICHIGAN