MEDICARE: MIKE'S WAY INC

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	AS410392760	MI
2	311ZA0620X	Adult Care Home Facility	AS410392759	MI
3	311ZA0620X	Adult Care Home Facility	AS410392757	MI
4	311ZA0620X	Adult Care Home Facility	AS410392756	MI

General Provider Information

NPI Number	:	1851893176
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MIKE'S WAY INC

Provider Business Mailing Address
First Line	:	9371 WESTVIEW DR SE
Second Line	:
City	:	BYRON CENTER
State	:	MI
Zip	:	49315-9324
Country	:	US
Telephone Number	:	616-877-4131
Fax Number	:	616-877-4231

Provider Business Practice Location Address
First Line	:	1552 ROBINSON RD SE
Second Line	:
City	:	GRAND RAPIDS
State	:	MI
Zip	:	49506-1748
Country	:	US
Telephone Number	:	616-608-4078
Fax Number	:	616-608-6832

Authorized Official
Title or Position	:	CFO
Name	:	MR. RANDAL L BENNETT
Credential	:
Telephone Number	:	616-929-3677

Provider Enumeration Date	:	03/02/2018
Last Update Date	:	03/17/2018

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