Provider Demographics
NPI:1699104513
Name:RETIREMENT LIVING MANAGEMENT OF FRUITPORT
Entity type:Organization
Organization Name:RETIREMENT LIVING MANAGEMENT OF FRUITPORT
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:KIM
Authorized Official - Middle Name:
Authorized Official - Last Name:WERNSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-798-2220
Mailing Address - Street 1:5425 CHESTNUT DR
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49444-7873
Mailing Address - Country:US
Mailing Address - Phone:231-798-2220
Mailing Address - Fax:231-798-2229
Practice Address - Street 1:5425 CHESTNUT DR
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49444-7873
Practice Address - Country:US
Practice Address - Phone:231-798-2220
Practice Address - Fax:231-798-2229
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-11-01
Last Update Date:2013-11-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL610288875310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility