Provider Demographics
NPI:1578681300
Name:BARUCH SLS, INC.
Entity type:Organization
Organization Name:BARUCH SLS, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF OPERATIONS
Authorized Official - Prefix:MRS
Authorized Official - First Name:CONNIE
Authorized Official - Middle Name:L
Authorized Official - Last Name:CLAUSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-285-0573
Mailing Address - Street 1:3196 KRAFT AVE SE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49512-2078
Mailing Address - Country:US
Mailing Address - Phone:616-285-0573
Mailing Address - Fax:616-464-2470
Practice Address - Street 1:640 W RANDALL ST
Practice Address - Street 2:
Practice Address - City:COOPERSVILLE
Practice Address - State:MI
Practice Address - Zip Code:49404-1306
Practice Address - Country:US
Practice Address - Phone:616-997-9253
Practice Address - Fax:616-997-7234
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:BARUCH SLS, INC.
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2007-03-27
Last Update Date:2009-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAL700070219310400000X
MIAL700070220310400000X
MIAL700088278310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI5197796Medicaid
MI5197876Medicaid
MI23D0975401OtherCLIA WAIVER ID
MI6967688Medicaid
MI23D0975401OtherCLIA WAIVER ID