Healthcare Provider Details

I. General information

NPI: 1942691191
Provider Name (Legal Business Name): STONERIDGE ADULT FOSTER CARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2015
Last Update Date: 02/10/2015
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 TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License NumberAL080338716
License Number StateMI

VIII. Authorized Official

Name: MRS. MICHELLE LYNN MOORE
Title or Position: MANAGER
Credential: RN
Phone: 269-758-3388