Healthcare Provider Details

I. General information

NPI: 1427566215
Provider Name (Legal Business Name): A SECOND CHANCE AT LIFE HOME CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/16/2018
Last Update Date: 01/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3212 EASTERN AVE SE STE D
GRAND RAPIDS MI
49508-2403
US

IV. Provider business mailing address

1644 GIDDINGS AVE SE
GRAND RAPIDS MI
49507-2225
US

V. Phone/Fax

Practice location:
  • Phone: 616-482-7703
  • Fax:
Mailing address:
  • Phone: 616-389-7802
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JENNIFER ROBERTSON
Title or Position: OWNER
Credential:
Phone: 616-389-7800