Healthcare Provider Details

I. General information

NPI: 1629670161
Provider Name (Legal Business Name): MRS. TARITA DOOLEY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/10/2020
Last Update Date: 11/10/2020
Certification Date: 11/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

905 BALLARD ST SE
GRAND RAPIDS MI
49507-2038
US

IV. Provider business mailing address

905 BALLARD ST SE
GRAND RAPIDS MI
49507-2038
US

V. Phone/Fax

Practice location:
  • Phone: 616-633-5354
  • Fax:
Mailing address:
  • Phone: 616-633-5354
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number4703100135
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 5
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: