# HOLLAND HOME

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- **Entity:** Organization
- **Status:** Active
- **Parent organization:** HOLLAND HOME
- **Other names:** Holland Home - Fulton Manor
- **Organization subpart:** Yes

## Provider details

- **NPI number:** 1972557460
- **Legal business name:** HOLLAND HOME
- **Authorized official:** MR. DAVID TIESENGA (CFO)
- **Authorized official phone:** (616) 235-5035

## Contact information

- **Practice address:** 1450 EAST FULTON, GRAND RAPIDS, MI 49503-3854
- **Practice address phone:** (616) 643-2600
- **Practice address fax:** (616) 643-2623
- **Mailing address:** 1450 EAST FULTON, GRAND RAPIDS, MI 49503-3854
- **Mailing address phone:** (616) 643-2600
- **Mailing address fax:** (616) 643-2623

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 314000000X | Skilled Nursing Facility | 14196 | MI | Yes |

## Other

- **Enumeration date:** 05/20/2006
- **Last updated:** 03/10/2016

## Other identifiers

| Code | Description | Identifier | Issuer | State |
| --- | --- | --- | --- | --- |
| 01 | — | 09887 | BCBS OF MICHIGAN | — |
| 05 | — | 2081311 | — | MI |