Provider Demographics
NPI:1215324876
Name:BEACON SPECIALIZED LIVING SERVICES INC
Entity type:Organization
Organization Name:BEACON SPECIALIZED LIVING SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATHAN
Authorized Official - Middle Name:
Authorized Official - Last Name:RATZLAFF
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-427-8400
Mailing Address - Street 1:555 RAILROAD ST
Mailing Address - Street 2:PO BOX 69
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1464
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:555 RAILROAD ST
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1464
Practice Address - Country:US
Practice Address - Phone:269-427-8400
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BEACON SPECIALIZED LIVING SERVICES INC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2015-04-22
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatryGroup - Multi-Specialty