Provider Demographics
NPI:1174907380
Name:CHERRY BLOSSOM MANOR, INC.
Entity type:Organization
Organization Name:CHERRY BLOSSOM MANOR, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:PATRICIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:HINDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-873-5377
Mailing Address - Street 1:PO BOX 332
Mailing Address - Street 2:
Mailing Address - City:HART
Mailing Address - State:MI
Mailing Address - Zip Code:49420-0332
Mailing Address - Country:US
Mailing Address - Phone:231-873-5377
Mailing Address - Fax:231-873-7108
Practice Address - Street 1:611 E MAIN ST
Practice Address - Street 2:SUITE B
Practice Address - City:HART
Practice Address - State:MI
Practice Address - Zip Code:49420-1190
Practice Address - Country:US
Practice Address - Phone:231-873-5377
Practice Address - Fax:231-873-7108
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-17
Last Update Date:2015-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAH640236763310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI4523065Medicaid