NPIMap

Organization Active NPI

Holland Home

  • Skilled Nursing Facility
  • Grand Rapids, MI
National Provider Identifier
1396799987
Registry record updated Apr 29, 2021
On this page

Key facts

NPPES NPI Registry
Primary specialty
Skilled Nursing FacilityTaxonomy code 314000000X
License
14208 Issued in MI
Legal business name
HOLLAND HOME
Practice address
2121 Raybrook St SE
Grand Rapids, MI 49546-5793
Phone
(616) 235-5002
Fax
(616) 235-5088
NPI assigned
May 19, 2006
Last updated
Apr 29, 2021By the provider in NPPES
Organization subpart
Yes
Parent organization
HOLLAND HOMEAs reported in NPPES

NPPES NPI Registry

Updated by the provider on Apr 29, 2021

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Mr. Adam Kinder
Title
Cfo
Phone
(616) 235-5015

Specialties & licenses 1

Specialty (taxonomy)CodeLicenseStatePrimary
Skilled Nursing Facility 314000000X 14208 MI Primary

Addresses

Primary practice location

2121 Raybrook St SE
Grand Rapids, MI 49546-5793

Mailing address

2121 Raybrook St SE
Grand Rapids, MI 49546-5793
Phone (616) 235-5002

Other identifiers 2

IdentifierTypeStateIssuer
2084260MedicaidMI
09891OtherBCBS OF MICHIGAN

Other names 1

  • Holland Home - Raybrook Manor Other name

Medicare participation

Medicare enrollment files
Medicare fee-for-service enrollment
Enrolled in MI

Enrollment records 1

Enrollment IDStateProvider typePAC IDDetails
O20050225000110 MI Part A Provider - Skilled Nursing Facility 1456304831 Practice locations: Grand Rapids, MI

NPI to CCN mapping 1

The Medicare certification numbers (CCNs) connected to NPI 1396799987. Details of each certification follow.

Skilled nursing facility certification: CCN 235440

Legal name
HOLLAND HOME
Doing business as
HOLLAND HOME - RAYBROOK MANOR
Certification status
Active
Provider type (POS)
Nursing home – SNF/NF dual certification
Participating since
Sep 1, 1985
Last certification
Feb 5, 2025
Beds
101
Ownership / control type
Nonprofit Corporation
Multi-facility organization
Holland Home
Organization structure
CorporationNon-profit
Incorporated
Dec 18, 1912 in MI
Enrollment address
2121 Raybrook St SE
Grand Rapids, MI 49546-5793
Nursing home name
HOLLAND HOME - RAYBROOK MANOR

Other NPIs with the same Medicare PAC ID 1

NPIs whose Medicare enrollments share a PECOS associate control ID (the same enrolled entity).

Care Compare: Nursing home

Medicare Care Compare
Listed as
Holland Home - Raybrook ManorCCN 235440 · All quality measures
Overall star rating
5 of 5
Health inspections
4 of 5
Staffing
5 of 5
Quality measures
5 of 5
Type
Medicare and Medicaid
Ownership
Non profit - Corporation
Certified
Sep 1, 1985
Medicare certification status
ActiveFrom the Provider of Services file
Certified beds
10190.7 residents per day on average
Penalties (3 years)
1Fines totaling $0

Processed by Care Compare on Aug 1, 2026.

Laboratory certificates & supplier records

Derived by NPIMap

These CMS records do not include an NPI. They are shown because their name and street address match this provider’s.

CLIA laboratory certificates

CLIA numberLaboratoryCertificateExpires
23D0651049Holland Home - Raybrook Manor2121 Raybrook SE, Grand Rapids, MI 49546Certificate of waiverAug 31, 2026

National Provider Directory

National Provider Directory
Tax ID family
Holland Home3 organizations share this tax ID, including this one
Part of
Holland Home

Other organizations with this tax ID 2

Organizations that report the same tax identification number in the National Provider Directory.

Ownership & related parties

All disclosed owners & managing parties 31

As disclosed on the Medicare enrollment (CMS All Owners files). Individuals include officers, directors and managing employees, who may not hold ownership.

NameRoleSinceShare
Ronald Duemler Individual Operational/Managerial Control Jun 26, 2000
Adp of the SNF Jun 26, 2000
Huntington Organization, Grand Rapids, MI Holding company, Financial institution Adp of the SNF Jan 1, 2009
Douglas Himmelein Individual Operational/Managerial Control Nov 1, 2021
Adp of the SNF Nov 1, 2021
Raymond James Organization, Grand Rapids, MI Holding company, Financial institution Adp of the SNF Jan 1, 2011
Carlos Hidalgo Individual Corporate Director Jul 1, 2022
Plante & Moran PLLC Organization, Southfield, MI LLC, Consulting firm Adp of the SNF Jan 1, 2003
Anne Tatreau Individual Operational/Managerial Control Sep 6, 2011
Adp of the SNF Sep 6, 2011
Concept Rehab, Inc. Organization, Toledo, OH Corporation Operational/Managerial Control Oct 1, 2025
Organization, Southfield, MI Adp of the SNF Dec 5, 2025
Philip Matro Individual Operational/Managerial Control Apr 14, 2021
Adp of the SNF Apr 14, 2021
David Smith Individual Corporate Director Jul 1, 2022
Troy Vugteveen Individual Corporate OfficerPresident & Ceo Jan 1, 2022
Corporate DirectorPresident & Ceo Jan 1, 2022
Operational/Managerial Control Jan 1, 2022
Saint Mary's Health Services Organization, Grand Rapids, MI Medical provider/supplier, Non-profit Adp of the SNF Jan 1, 2000
Mary Ursul Individual Corporate Director Jul 1, 2012
Christian Living Services Organization, Grand Rapids, MI Non-profit 5% Or Greater Direct Ownership Interest Jan 1, 2009 100%
Mark Johnson Individual Corporate OfficerVice Chair/Secretary Jul 1, 2025
Corporate Director Jul 21, 2021
Susan L Vogel-Vanderson Individual Corporate DirectorDirector Jul 1, 2011
Gilbert Segovia Individual Corporate Director Jul 1, 2022
Brandyn Deckinga Individual Operational/Managerial Control Aug 8, 2019
Adp of the SNF Aug 8, 2019
Scott Schaab Individual Operational/Managerial Control Jan 1, 2006
Adp of the SNF Jan 1, 2006
Timothy Myers Individual Operational/Managerial Control Jun 30, 2016
Adp of the SNF Jun 30, 2016
Gary P Malburg Individual Corporate OfficerTreasurer Jul 1, 2012
Corporate Director Jul 1, 2012
David Knibbe Individual Corporate Director Dec 1, 2016
Scott Demaagd Individual Corporate Director Jul 1, 2025
Sam R Watson Individual Corporate Director Jul 1, 2017
Nick Thole Individual Corporate Director Dec 1, 2016
Jean M Nagelkerk Individual Corporate Director Jul 1, 2015
Marie Vanderkooi Individual Corporate Director Jul 1, 2025
Adam Kinder Individual Corporate OfficerCfo Apr 4, 2021
Operational/Managerial Control Apr 4, 2021
Nelson Sanchez Individual Corporate OfficerBoard Chair Jul 1, 2025
Corporate Director Jul 1, 2017
Authenticity Marketing Group Organization, Grand Rapids, MI Corporation, Consulting firm Adp of the SNF Jan 1, 2014

Owners & managing parties with NPI records 5

Owners and managing parties disclosed on this facility’s Medicare enrollment that are themselves Medicare-enrolled.

All facility ownership & control disclosures 3

Facilities whose Medicare enrollment lists this provider’s PECOS associate ID as an owner or managing party.

FacilityTypeRoleSince
Atrio Home HealthGrand Rapids, MI, CCN 237208 Home health agency Operational/Managerial Control (100%) Jul 8, 2016
Atrio Home Health LakeshoreHolland, MI, CCN 237411 Home health agency Operational/Managerial Control (100%) Jul 8, 2016
Faith Hospice at Trillium WoodsByron Center, MI, CCN 231570 Hospice Operational/Managerial Control (100%) Jul 30, 1992

Owned or controlled facilities with NPI records 3

Facilities whose Medicare enrollment lists this provider as an owner, officer, director or managing party.

Facilities with the same owner 17

Facilities that share an organizational owner with 5% or greater ownership or operational control.

View all 17

Parent organization (reported in NPPES) 1

This organization reports itself as a subpart in NPPES; the parent’s legal name matches this organization in the same state.

Practitioners & affiliated clinicians

Practitioners 2

Individual providers connected to this organization through Medicare benefit reassignment, Care Compare group membership or National Provider Directory roles, and the practitioner matching its NPPES authorized official.

Affiliated clinicians 2

Clinicians who list this facility as an affiliation in Medicare Care Compare.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1147996800000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1619654400000",
    "number": "1396799987",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "2121 RAYBROOK ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495465793",
            "telephone_number": "616-235-5002",
            "fax_number": "616-235-5088"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "2121 RAYBROOK ST SE",
            "city": "GRAND RAPIDS",
            "state": "MI",
            "postal_code": "495465793",
            "telephone_number": "616-235-5002",
            "fax_number": "616-235-5088"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "HOLLAND HOME",
        "organizational_subpart": "YES",
        "parent_organization_legal_business_name": "HOLLAND HOME",
        "enumeration_date": "2006-05-19",
        "last_updated": "2021-04-29",
        "certification_date": "2021-04-29",
        "status": "A",
        "authorized_official_last_name": "KINDER",
        "authorized_official_first_name": "ADAM",
        "authorized_official_title_or_position": "CFO",
        "authorized_official_telephone_number": "616-235-5015",
        "authorized_official_name_prefix": "Mr."
    },
    "taxonomies": [
        {
            "code": "314000000X",
            "taxonomy_group": "",
            "desc": "Skilled Nursing Facility",
            "state": "MI",
            "license": "14208",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "2084260",
            "state": "MI"
        },
        {
            "code": "01",
            "desc": "Other (non-Medicare)",
            "issuer": "BCBS OF MICHIGAN",
            "identifier": "09891",
            "state": null
        }
    ],
    "endpoints": [],
    "other_names": [
        {
            "organization_name": "Holland Home - Raybrook Manor",
            "code": "5",
            "type": "Other Name"
        },
        {
            "organization_name": "Holland Home - Raybrook Manor",
            "code": "5",
            "type": "Other Name"
        }
    ]
}

Other providers in Grand Rapids, MI

Sources for this page

Verify at the official NPI Registry.