Healthcare Provider Details

I. General information

NPI: 1841789823
Provider Name (Legal Business Name): SATARA ALICIA MCMILLIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/06/2018
Last Update Date: 05/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2115 FRANCIS AVE SE
GRAND RAPIDS MI
49507-3016
US

IV. Provider business mailing address

2115 FRANCIS AVE SE
GRAND RAPIDS MI
49507-3016
US

V. Phone/Fax

Practice location:
  • Phone: 616-633-3953
  • Fax:
Mailing address:
  • Phone: 616-633-3953
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberAS410389803
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: