Basic Information
| Provider Information | |||||||||
| NPI: | 1790739282 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | FAITH HOSPICE | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | HOSPICE OF HOLLAND HOME AND FAITH HOSPICE AT TRILLIUM WOODS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2100 RAYBROOK ST SE | ||||||||
| Address2: | STE 303 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162355100 | ||||||||
| FaxNumber: | 6162355050 | ||||||||
| Practice Location | |||||||||
| Address1: | 2100 RAYBROOK ST SE | ||||||||
| Address2: | STE 303 | ||||||||
| City: | GRAND RAPIDS | ||||||||
| State: | MI | ||||||||
| PostalCode: | 495465783 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6162355100 | ||||||||
| FaxNumber: | 6162355050 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/20/2006 | ||||||||
| LastUpdateDate: | 04/29/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | KINDER | ||||||||
| AuthorizedOfficialFirstName: | ADAM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CFO | ||||||||
| AuthorizedOfficialTelephone: | 6162355015 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 04/29/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251G00000X | Y | Agencies | Hospice Care, Community Based |
ID Information
| ID | Type | State | Issuer | Description | 08762 | 01 | BCBS OF MICHIGAN | OTHER | 3161730 | 05 | MI | MEDICAID |