Provider Demographics
NPI:1033287792
Name:HOLLAND HOME
Entity type:Organization
Organization Name:HOLLAND HOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CFO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:
Authorized Official - Last Name:TIESENGA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-235-5035
Mailing Address - Street 1:2100 RAYBROOK ST SE
Mailing Address - Street 2:SUITE 300
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49546-5783
Mailing Address - Country:US
Mailing Address - Phone:616-235-5000
Mailing Address - Fax:616-235-5680
Practice Address - Street 1:2100 RAYBROOK ST SE
Practice Address - Street 2:SUITE 300
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-5783
Practice Address - Country:US
Practice Address - Phone:616-235-5000
Practice Address - Fax:616-235-5680
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-01
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Not Answered314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
902015Medicare ID - Type Unspecified