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General NPI Number Information
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NPI Number | 1174873665
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Entity Type | Organization
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Legal Business Name | AGAPE HOME AT BLUEBERRY FIELDS INC.
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Dates
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Enumeration Date | 09/12/2012
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Last Update Date | 09/12/2012
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Provider Practice Location Address
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Address Line | 4747 E MT. GARFIELD RD.
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City | FRUITPORT
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State | MI
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Zip | 49415
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Country | US
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Telephone | 231-780-2229
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Fax | 231-780-9000
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Provider Business Mailing Address
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Address Line | 572 LAKE FOREST LANE
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City | MUSKEGON
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State | MI
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Zip | 49441
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Country | US
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Telephone | 231-780-2229
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Fax | 231-780-9000
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Authorized Official
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Title or Position | PRESIDENT
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Name | MR. RICHARD HAROLD EBELING
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Credential |
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Telephone | 231-780-2229
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 310400000X
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Taxonomy Name | Assisted Living Facility
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License Number | AL601304298
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License Number State | MI
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