Provider Demographics
NPI:1649824913
Name:PINE VALLEY ASSISTED LIVING
Entity type:Organization
Organization Name:PINE VALLEY ASSISTED LIVING
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINSTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:A
Authorized Official - Last Name:ONGWELA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-598-5595
Mailing Address - Street 1:1155 N 26TH ST
Mailing Address - Street 2:
Mailing Address - City:KALAMAZOO
Mailing Address - State:MI
Mailing Address - Zip Code:49048-9221
Mailing Address - Country:US
Mailing Address - Phone:269-598-5595
Mailing Address - Fax:
Practice Address - Street 1:1155 N 26TH ST
Practice Address - Street 2:
Practice Address - City:KALAMAZOO
Practice Address - State:MI
Practice Address - Zip Code:49048-9221
Practice Address - Country:US
Practice Address - Phone:269-598-5595
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-25
Last Update Date:2019-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility