Healthcare Provider Details

I. General information

NPI: 1689102931
Provider Name (Legal Business Name): JERRY'S DREAM ADULT HOMES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2017
Last Update Date: 05/31/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1124 W LEONARD CT NW
GRAND RAPIDS MI
49534-6835
US

IV. Provider business mailing address

PO BOX 1086
GRAND RAPIDS MI
49501-1086
US

V. Phone/Fax

Practice location:
  • Phone: 616-735-4681
  • Fax:
Mailing address:
  • Phone: 616-293-7198
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAS410269763
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAS410269764
License Number StateMI

VIII. Authorized Official

Name: VICKIE RUNYON
Title or Position: OWNER
Credential:
Phone: 616-293-7198