Provider Demographics
NPI:1730514290
Name:PINE RIDGE ADULT CARE HOME, LLC
Entity type:Organization
Organization Name:PINE RIDGE ADULT CARE HOME, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:WESTERHOF
Authorized Official - Suffix:I
Authorized Official - Credentials:
Authorized Official - Phone:616-399-1774
Mailing Address - Street 1:15467 PORT SHELDON ST
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-9715
Mailing Address - Country:US
Mailing Address - Phone:616-399-1774
Mailing Address - Fax:616-738-0009
Practice Address - Street 1:15467 PORT SHELDON ST
Practice Address - Street 2:
Practice Address - City:WEST OLIVE
Practice Address - State:MI
Practice Address - Zip Code:49460-9715
Practice Address - Country:US
Practice Address - Phone:616-399-1774
Practice Address - Fax:616-738-0009
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-09-03
Last Update Date:2013-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL700079149310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility