Healthcare Provider Details

I. General information

NPI: 1235670696
Provider Name (Legal Business Name): RANDY'S HOUSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/17/2017
Last Update Date: 03/17/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

203 E WASHINGTON ST
GREENVILLE MI
48838-1944
US

IV. Provider business mailing address

203 E WASHINGTON ST
GREENVILLE MI
48838-1944
US

V. Phone/Fax

Practice location:
  • Phone: 616-232-2915
  • Fax: 616-835-9101
Mailing address:
  • Phone: 616-232-2915
  • Fax: 616-835-9101

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code324500000X
TaxonomySubstance Abuse Rehabilitation Facility
License NumberSO410408
License Number StateMI

VIII. Authorized Official

Name: MR. MICHAEL EUGENE HELMER
Title or Position: EXECUTIVE DIRECTOR
Credential:
Phone: 616-498-4608