Healthcare Provider Details

I. General information

NPI: 1497368187
Provider Name (Legal Business Name): STACIA NICHOLE LARIVE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/24/2020
Last Update Date: 08/24/2020
Certification Date: 08/24/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 VINE ST
CADILLAC MI
49601-2435
US

IV. Provider business mailing address

105 VINE ST
CADILLAC MI
49601-2435
US

V. Phone/Fax

Practice location:
  • Phone: 231-884-1988
  • Fax:
Mailing address:
  • Phone: 231-884-1988
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAF830403510
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: