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General NPI Number Information
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NPI Number | 1942691191
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Entity Type | Organization
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Legal Business Name | STONERIDGE ADULT FOSTER CARE
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Dates
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Enumeration Date | 02/10/2015
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Last Update Date | 02/10/2015
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Provider Practice Location Address
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Address Line | 4825 FRUIN RD
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City | BELLEVUE
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State | MI
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Zip | 49021-8209
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Country | US
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Telephone | 269-758-3388
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Fax | 269-758-3488
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Provider Business Mailing Address
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Address Line | 4825 FRUIN RD
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City | BELLEVUE
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State | MI
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Zip | 49021-8209
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Country | US
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Telephone | 269-758-3388
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Fax | 269-758-3488
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. MICHELLE LYNN MOORE
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Credential | RN
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Telephone | 269-758-3388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 3104A0630X
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Taxonomy Name | Assisted Living Facility (Behavioral Disturbances)
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License Number | AL080338716
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License Number State | MI
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