Healthcare Provider Details

I. General information

NPI: 1295986503
Provider Name (Legal Business Name): MRS. MELISSA MARIA LUNA-KEATON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/06/2008
Last Update Date: 10/06/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5135 E MOUNT MORRIS RD
MOUNT MORRIS MI
48458-9721
US

IV. Provider business mailing address

5135 E MOUNT MORRIS RD
MOUNT MORRIS MI
48458-9721
US

V. Phone/Fax

Practice location:
  • Phone: 810-515-4278
  • Fax:
Mailing address:
  • Phone: 810-515-4278
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253J00000X
TaxonomyFoster Care Agency
License NumberAS250010894
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License NumberAS250010894
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: