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General NPI Number Information
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NPI Number | 1730616509
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Entity Type | Organization
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Legal Business Name | EVERGREEN MEADOW AFC
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Dates
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Enumeration Date | 05/11/2017
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Last Update Date | 05/11/2017
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Provider Practice Location Address
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Address Line | 1944 BUTTRICK AVE SE
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City | ADA
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State | MI
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Zip | 49301-9204
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Country | US
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Telephone | 616-682-0848
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Fax |
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Provider Business Mailing Address
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Address Line | 1944 BUTTRICK AVE SE
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City | ADA
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State | MI
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Zip | 49301-9204
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Country | US
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Telephone | 616-682-0848
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Fax |
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Authorized Official
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Title or Position | AFC OPERATOR/OWNER
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Name | MR. DANIEL PATRICK ERDMAN
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Credential |
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Telephone | 616-682-0848
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 311ZA0620X
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Taxonomy Name | Adult Care Home Facility
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License Number | AF410255092
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License Number State | MI
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