MEDICARE: ASCENSION HEALTH III AFC LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	311ZA0620X	Adult Care Home Facility	AS410386016	MI

General Provider Information

NPI Number	:	1558800284
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ASCENSION HEALTH III AFC LLC

Provider Business Mailing Address
First Line	:	210 HODENPYL RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-2060
Country	:	US
Telephone Number	:	248-342-2698
Fax Number	:

Provider Business Practice Location Address
First Line	:	1947 MILLBANK ST SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49508-2674
Country	:	US
Telephone Number	:	616-805-4203
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	NADINE CARLSON
Credential	:
Telephone Number	:	248-342-2698

Provider Enumeration Date	:	02/14/2017
Last Update Date	:	02/14/2017

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