Healthcare Provider Details

I. General information

NPI: 1043093404
Provider Name (Legal Business Name): COMMUNITY CARE AFFORDABLE & SUPPORTIVE HOUSING LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/17/2023
Last Update Date: 08/17/2023
Certification Date: 08/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

77 MONROE CENTER ST NW STE 600
GRAND RAPIDS MI
49503-2911
US

IV. Provider business mailing address

77 MONROE CENTER ST NW STE 600
GRAND RAPIDS MI
49503-2911
US

V. Phone/Fax

Practice location:
  • Phone: 616-514-2609
  • Fax:
Mailing address:
  • Phone: 616-514-2609
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: JERICA BUCHANAN
Title or Position: OWNER
Credential:
Phone: 616-514-2609