Provider Demographics
NPI:1326025776
Name:DEBOER, INC.
Entity type:Organization
Organization Name:DEBOER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:CONNI
Authorized Official - Middle Name:
Authorized Official - Last Name:MCGLYNN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-777-2511
Mailing Address - Street 1:1750 VULCAN ST
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49442-6048
Mailing Address - Country:US
Mailing Address - Phone:231-777-2511
Mailing Address - Fax:231-777-4500
Practice Address - Street 1:1684 VULCAN ST
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49442-6070
Practice Address - Country:US
Practice Address - Phone:231-777-2511
Practice Address - Fax:231-777-4500
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-12-28
Last Update Date:2013-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAH610236808310400000X
MI614020314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4556244Medicaid
MIDH0255884OtherBLUE CROSS STATE ID
MI700F11095OtherBLUE CROSS PROVIDER NUMBER
MIP00093747OtherRAILROAD MEDICARE
MI4556244Medicaid
MI1613755Medicare PIN
MIDH0255884OtherBLUE CROSS STATE ID