Healthcare Provider Details

I. General information

NPI: 1023535754
Provider Name (Legal Business Name): PROFESSIONAL EXPERIENCED ASSISTANT CARING FOR THE ELDERLY OF MIND
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/23/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2410 INVERNESS ROAD
GRAND RAPIDS MI
49546
US

IV. Provider business mailing address

2410 INVERNESS RD SE
GRAND RAPIDS MI
49546-5529
US

V. Phone/Fax

Practice location:
  • Phone: 616-920-0369
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code347C00000X
TaxonomyPrivate Vehicle
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MR. ZACHARY ZWART
Title or Position: PRESIDENT OF SALES & MARKETING
Credential:
Phone: 320-444-6680