Provider Demographics
NPI:1306876438
Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Entity type:Organization
Organization Name:CENTERWELL CERTIFIED HEALTHCARE CORP.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED SIGNATORY
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-942-5744
Mailing Address - Street 1:6330 SPRINT PKWY STE 300
Mailing Address - Street 2:
Mailing Address - City:OVERLAND PARK
Mailing Address - State:KS
Mailing Address - Zip Code:66211-1157
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:625 KENMOOR AVE SE
Practice Address - Street 2:SUITE 306
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49546-2395
Practice Address - Country:US
Practice Address - Phone:616-942-5744
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-04
Last Update Date:2023-11-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI2887444Medicaid
237222Medicare Oscar/Certification
0E836OtherMI-COMMERCIAL NUMBER
1015681-0001OtherMI-COMMERCIAL NUMBER
1018534OtherMI-COMMERCIAL NUMBER
MI152887444Medicaid
MI154362680Medicaid
237222Medicare Oscar/Certification
113414024OtherMI-COMMERCIAL NUMBER
=========OtherMI-COMMERCIAL NUMBER
113414024DOtherMI-COMMERCIAL NUMBER
126718OtherMI-COMMERCIAL NUMBER
126683OtherMI-COMMERCIAL NUMBER
=========094OtherMI-CHAMPUS
013100POtherMI-COMMERCIAL NUMBER
1998308OtherMI-COMMERCIAL NUMBER
=========000OtherMI-COMMERCIAL NUMBER
MI2887444Medicaid
1015680-0001OtherMI-COMMERCIAL NUMBER
MI20726Medicaid