Provider Demographics
NPI:1649296260
Name:ALLEGAN NURSING HOME, LLC
Entity type:Organization
Organization Name:ALLEGAN NURSING HOME, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE VICE PRESIDENT AND CFO
Authorized Official - Prefix:
Authorized Official - First Name:J.
Authorized Official - Middle Name:LINDSEY
Authorized Official - Last Name:DOOD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-957-3957
Mailing Address - Street 1:3075 ORCHARD VISTA DR SE
Mailing Address - Street 2:SUITE 100
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-7069
Mailing Address - Country:US
Mailing Address - Phone:616-957-3957
Mailing Address - Fax:616-957-1556
Practice Address - Street 1:1200 ELY ST
Practice Address - Street 2:
Practice Address - City:ALLEGAN
Practice Address - State:MI
Practice Address - Zip Code:49010-9368
Practice Address - Country:US
Practice Address - Phone:269-673-5494
Practice Address - Fax:269-673-2781
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-15
Last Update Date:2008-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI034040314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2831215Medicaid
235264Medicare ID - Type UnspecifiedPROVIDER ID