Healthcare Provider Details

I. General information

NPI: 1548700545
Provider Name (Legal Business Name): SILVER SPARROW AFC HOME
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/24/2017
Last Update Date: 02/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1316 ELLIOTT ST SE
GRAND RAPIDS MI
49507-2851
US

IV. Provider business mailing address

1316 ELLIOTT ST SE
GRAND RAPIDS MI
49507-2851
US

V. Phone/Fax

Practice location:
  • Phone: 616-881-5898
  • Fax:
Mailing address:
  • Phone: 616-881-5898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAF410287362
License Number StateMI

VIII. Authorized Official

Name: MS. LAURA JO ALEXANDER
Title or Position: SOLE PROPRIETOR AND AFC PROVIDER
Credential:
Phone: 616-881-5898