Healthcare Provider Details

I. General information

NPI: 1053850776
Provider Name (Legal Business Name): FANNVIEW AFC LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/14/2017
Last Update Date: 02/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1948 MILLBANK ST SE
GRAND RAPIDS MI
49508-2673
US

IV. Provider business mailing address

210 HODENPYL RD SE
GRAND RAPIDS MI
49506-2060
US

V. Phone/Fax

Practice location:
  • Phone: 616-350-9124
  • Fax:
Mailing address:
  • Phone: 248-342-2698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberAS410317479
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License NumberAS410317479
License Number StateMI

VIII. Authorized Official

Name: NADINE CARLSON
Title or Position: OWNER
Credential:
Phone: 248-342-2698