MEDICARE: M.O.M

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	251J00000X	Nursing Care Agency	230006976540402	MI

General Provider Information

NPI Number	:	1982964144
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	M.O.M

Provider Business Mailing Address
First Line	:	9276 MONROE RD
Second Line	:
City	:	LAKE
State	:	MI
Zip	:	48632-9108
Country	:	US
Telephone Number	:	616-594-4465
Fax Number	:

Provider Business Practice Location Address
First Line	:	9276 MONROE RD
Second Line	:
City	:	LAKE
State	:	MI
Zip	:	48632-9108
Country	:	US
Telephone Number	:	616-594-4465
Fax Number	:

Authorized Official
Title or Position	:	CERTIFIED NURSE AIDE
Name	:	MRS. SYLVIA ANN DUFLO
Credential	:	CNA
Telephone Number	:	616-594-4465

Provider Enumeration Date	:	05/22/2012
Last Update Date	:	05/22/2012

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Directions to “M.O.M ” Practice Location

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