Healthcare Provider Details

I. General information

NPI: 1720630734
Provider Name (Legal Business Name): STONE RIDGE AFC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/10/2019
Last Update Date: 07/10/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4825 FRUIN RD
BELLEVUE MI
49021-8209
US

IV. Provider business mailing address

4825 FRUIN RD
BELLEVUE MI
49021-8209
US

V. Phone/Fax

Practice location:
  • Phone: 269-758-3388
  • Fax: 269-758-3488
Mailing address:
  • Phone: 269-758-3388
  • Fax: 269-758-3488

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code311500000X
TaxonomyAlzheimer Center (Dementia Center)
License Number
License Number State

VIII. Authorized Official

Name: WILLIAM SOWLE
Title or Position: OWNER/ADMIN
Credential:
Phone: 616-335-4865