Organization
VISTA GRANDE VILLA
Active
Organization subpart
No
Provider details
NPI number
Authorized official
MS. ELLEN A. KEATLEY (PRESIDENT)
(517) 787-0222
Entity
Organization
Contact information
Practice address
2251 SPRINGPORT RD, JACKSON, MI 49202-1496
(517) 787-0222
(517) 787-6909
Mailing address
2251 SPRINGPORT RD, JACKSON, MI 49202-1496
(517) 787-0222
(517) 787-6909
Taxonomy
Speciality
Code
Description
License number
State
314000000X
Skilled Nursing Facility
Primary
384210
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
09716
BLUE CROSS BLUE SH. OF MI
MI
05
—
2081106
—
MI
Enumeration date
12/05/2005
Last updated
11/29/2011
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