=====================================================
General NPI Number Information
=====================================================
NPI Number | 1275072654
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GRAGEVI AFC HOME
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/17/2017
-----------------------------------------------------
Last Update Date | 02/17/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5408 MILLS RIDGE DR SW
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-8390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-257-6956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5408 MILLS RIDGE DR SW
-----------------------------------------------------
City | GRANDVILLE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49418-8390
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-257-6956
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | ADULT FOSTER CARE PROVIDER
-----------------------------------------------------
Name | MRS. HEIDI GRAGEVI
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 616-257-6956
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 253J00000X
-----------------------------------------------------
Taxonomy Name | Foster Care Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------