Healthcare Provider Details

I. General information

NPI: 1598445124
Provider Name (Legal Business Name): MARCIA LUCILLE KOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/19/2023
Last Update Date: 07/19/2023
Certification Date: 07/19/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12955 68TH ST SE
ALTO MI
49302
US

IV. Provider business mailing address

12955 68TH ST SE
ALTO MI
49302
US

V. Phone/Fax

Practice location:
  • Phone: 616-868-0001
  • Fax: 616-868-0030
Mailing address:
  • Phone: 616-868-0001
  • Fax: 616-868-0030

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAM410416004
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: