Healthcare Provider Details

I. General information

NPI: 1619404308
Provider Name (Legal Business Name): SHEDRICE'S AFC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/12/2017
Last Update Date: 05/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

246 POWELL SE AVE
GRAND RAPIDS MI
49507
US

IV. Provider business mailing address

246 POWELL ST SE
GRAND RAPIDS MI
49507-1176
US

V. Phone/Fax

Practice location:
  • Phone: 616-248-1720
  • Fax: 616-248-1720
Mailing address:
  • Phone: 616-248-1720
  • Fax: 616-248-1720

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code385HR2060X
TaxonomyChild Intellectual and/or Developmental Disabilities Respite Care
License NumberAS410385361
License Number StateMI

VIII. Authorized Official

Name: SHELIA LYNN BURRELL
Title or Position: OWENER
Credential:
Phone: 616-248-1720