Provider Demographics
NPI:1487066734
Name:GREAT LIVING FOSTER CARE
Entity type:Organization
Organization Name:GREAT LIVING FOSTER CARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:BERGELINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLORVILUS
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:269-815-2087
Mailing Address - Street 1:8973 PIONEER CT
Mailing Address - Street 2:
Mailing Address - City:BERRIEN SPRINGS
Mailing Address - State:MI
Mailing Address - Zip Code:49103-1700
Mailing Address - Country:US
Mailing Address - Phone:269-815-2087
Mailing Address - Fax:269-815-5064
Practice Address - Street 1:8973 PIONEER CT
Practice Address - Street 2:
Practice Address - City:BERRIEN SPRINGS
Practice Address - State:MI
Practice Address - Zip Code:49103-1700
Practice Address - Country:US
Practice Address - Phone:269-815-2087
Practice Address - Fax:269-815-5064
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-05-21
Last Update Date:2014-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF110317417320800000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness