Provider Demographics
NPI:1750718078
Name:WILDS RIVER REST
Entity type:Organization
Organization Name:WILDS RIVER REST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:JANICE
Authorized Official - Middle Name:ELLEN
Authorized Official - Last Name:WILDS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-695-6074
Mailing Address - Street 1:12409 N RED BUD TRL
Mailing Address - Street 2:
Mailing Address - City:BUCHANAN
Mailing Address - State:MI
Mailing Address - Zip Code:49107-9139
Mailing Address - Country:US
Mailing Address - Phone:269-695-6074
Mailing Address - Fax:269-697-0474
Practice Address - Street 1:12409 N RED BUD TRL
Practice Address - Street 2:
Practice Address - City:BUCHANAN
Practice Address - State:MI
Practice Address - Zip Code:49107-9139
Practice Address - Country:US
Practice Address - Phone:269-695-6074
Practice Address - Fax:269-697-0474
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-01
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM110064771311Z00000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No311Z00000XNursing & Custodial Care FacilitiesCustodial Care Facility