Healthcare Provider Details

I. General information

NPI: 1881102788
Provider Name (Legal Business Name): A GRAND RAPIDS SENIOR SOCIAL EXCHANGE AND ADULT DAY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/14/2018
Last Update Date: 07/02/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3212 EASTERN AVE SE
GRAND RAPIDS MI
49508
US

IV. Provider business mailing address

PO BOX 7004
GRAND RAPIDS MI
49510-7004
US

V. Phone/Fax

Practice location:
  • Phone: 616-329-4101
  • Fax:
Mailing address:
  • Phone: 616-329-4101
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State

VIII. Authorized Official

Name: MRS. JODIE LYNN ROBERTSON
Title or Position: OWNER
Credential: NA
Phone: 616-329-4101