MEDICARE: LIVING ROOTS LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1487071213
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	LIVING ROOTS LLC

Provider Business Mailing Address
First Line	:	3980 CHICAGO DR SW
Second Line	:	SUITE 100
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-1392
Country	:	US
Telephone Number	:	616-575-8519
Fax Number	:	616-575-9078

Provider Business Practice Location Address
First Line	:	3980 CHICAGO DR SW
Second Line	:	SUITE 100
City	:	GRANDVILLE
State	:	MI
Zip	:	49418-1392
Country	:	US
Telephone Number	:	616-575-8519
Fax Number	:	616-575-9078

Authorized Official
Title or Position	:	OWNER/MANAGER
Name	:	MR. BRIAN WILSON
Credential	:
Telephone Number	:	616-575-8519

Provider Enumeration Date	:	03/18/2014
Last Update Date	:	05/25/2016

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Directions to “LIVING ROOTS LLC ” Practice Location

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