MEDICARE: MOMMAS HOUSE 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	376G00000X	Nursing Home Administrator

General Provider Information

NPI Number	:	1669338919
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MOMMAS HOUSE LLC

Provider Business Mailing Address
First Line	:	279 CHURCH ST
Second Line	:
City	:	BELLEVILLE
State	:	MI
Zip	:	48111-2627
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	279 CHURCH ST
Second Line	:
City	:	BELLEVILLE
State	:	MI
Zip	:	48111-2627
Country	:	US
Telephone Number	:	313-642-5372
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	MIA HOLLY
Credential	:
Telephone Number	:	734-695-9146

Provider Enumeration Date	:	12/30/2025
Last Update Date	:	12/30/2025

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Directions to “MOMMAS HOUSE LLC ” Practice Location

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