Provider Demographics
NPI:1689672792
Name:ATRIUM SOUTH HAVEN LLC
Entity type:Organization
Organization Name:ATRIUM SOUTH HAVEN LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF ACCOUNTING OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:DENNIS
Authorized Official - Middle Name:
Authorized Official - Last Name:LOCKHART
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:614-416-0600
Mailing Address - Street 1:850 PHILLIPS ST
Mailing Address - Street 2:
Mailing Address - City:SOUTH HAVEN
Mailing Address - State:MI
Mailing Address - Zip Code:49090-1845
Mailing Address - Country:US
Mailing Address - Phone:269-637-5147
Mailing Address - Fax:269-637-4943
Practice Address - Street 1:850 PHILLIPS ST
Practice Address - Street 2:
Practice Address - City:SOUTH HAVEN
Practice Address - State:MI
Practice Address - Zip Code:49090-1845
Practice Address - Country:US
Practice Address - Phone:269-637-5147
Practice Address - Fax:269-637-4943
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-07-12
Last Update Date:2025-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI80-4030314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI60 3495037Medicaid
MI09947OtherBCBS PROVIDER CODE
MI60 3495037Medicaid