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General NPI Number Information
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NPI Number | 1801240890
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Entity Type | Organization
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Legal Business Name | HOME ASSISTED LIVING PROGRAM
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Dates
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Enumeration Date | 04/16/2016
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Last Update Date | 04/16/2016
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Provider Practice Location Address
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Address Line | 4429 RABIDUE RD
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City | CLYDE
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State | MI
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Zip | 48049-2926
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Country | US
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Telephone | 810-334-4481
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Fax |
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Provider Business Mailing Address
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Address Line | 4429 RABIDUE RD
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City | CLYDE
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State | MI
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Zip | 48049-2926
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Country | US
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Telephone | 810-334-4481
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Fax |
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Authorized Official
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Title or Position | ADMINISTRATOR
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Name | ANGELA MARIE KOPER
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Credential | BHA
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Telephone | 810-334-4481
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number | E7830A
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License Number State | MI
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