Healthcare Provider Details

I. General information

NPI: 1053837922
Provider Name (Legal Business Name): RAEKESHA LACHELLE MCMILLIAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2017
Last Update Date: 08/22/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

820 WATKINS ST SE
GRAND RAPIDS MI
49507-1345
US

IV. Provider business mailing address

1232 KALAMAZOO AVE SE
GRAND RAPIDS MI
49507-1923
US

V. Phone/Fax

Practice location:
  • Phone: 616-427-4570
  • Fax:
Mailing address:
  • Phone: 616-427-4570
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0630X
TaxonomyAssisted Living Facility (Behavioral Disturbances)
License NumberAS410388538
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: