MEDICARE: ALICA M WRZESINSKI

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	253J00000X	Foster Care Agency	AF800238276	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1609376425
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ALICA M WRZESINSKI

Provider Business Mailing Address
First Line	:	56345 COUNTY ROAD 384
Second Line	:
City	:	GRAND JUNCTION
State	:	MI
Zip	:	49056-9753
Country	:	US
Telephone Number	:	269-434-6959
Fax Number	:

Provider Business Practice Location Address
First Line	:	56345 COUNTY ROAD 384
Second Line	:
City	:	GRAND JUNCTION
State	:	MI
Zip	:	49056-9753
Country	:	US
Telephone Number	:	269-434-6959
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/19/2018
Last Update Date	:	02/19/2018

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