Provider Demographics
NPI:1720350341
Name:CHRISTIAN REST HOME ASSOCIATION
Entity Type:Organization
Organization Name:CHRISTIAN REST HOME ASSOCIATION
Other - Org Name:EDISON ASSISTED LIVING CENTER
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:HORJUS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-453-0581
Mailing Address - Street 1:1010 EDISON AVE NW
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49504-3918
Mailing Address - Country:US
Mailing Address - Phone:616-453-0581
Mailing Address - Fax:616-791-0910
Practice Address - Street 1:1010 EDISON AVE NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49504-3918
Practice Address - Country:US
Practice Address - Phone:616-453-0581
Practice Address - Fax:616-791-0910
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:CHRISTIAN REST HOME ASSOCIATION
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2012-01-27
Last Update Date:2012-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAH410236778310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIAH410236778OtherMICHIGAN DEPARTMENT OF HUMAN SERVICES