# VISTA GRANDE VILLA

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1477537397
- **Authorized official:** MS. ELLEN A. KEATLEY (PRESIDENT)
- **Authorized official phone:** (517) 787-0222

## Contact information

- **Practice address:** 2251 SPRINGPORT RD, JACKSON, MI 49202-1496
- **Practice address phone:** (517) 787-0222
- **Practice address fax:** (517) 787-6909
- **Mailing address:** 2251 SPRINGPORT RD, JACKSON, MI 49202-1496
- **Mailing address phone:** (517) 787-0222
- **Mailing address fax:** (517) 787-6909

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 384210 | MI | Yes |

## Other

- **Enumeration date:** 12/05/2005
- **Last updated:** 11/29/2011

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 09716 | BLUE CROSS BLUE SH. OF MI | MI |
| 05 | — | 2081106 | — | MI |