1174873665 NPI number — AGAPE HOME AT BLUEBERRY FIELDS INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174873665 NPI number — AGAPE HOME AT BLUEBERRY FIELDS INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
AGAPE HOME AT BLUEBERRY FIELDS INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1174873665
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
572 LAKE FOREST LANE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
MUSKEGON
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49441
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-780-2229
Provider Business Mailing Address Fax Number:
231-780-9000

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4747 E MT. GARFIELD RD.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FRUITPORT
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49415
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-780-2229
Provider Business Practice Location Address Fax Number:
231-780-9000
Provider Enumeration Date:
09/12/2012

Additional Information

Authorized Official

Authorized Official Last Name:
EBELING
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
HAROLD
Authorized Official Title or Position:
PRESIDENT
Authorized Official Telephone Number:
231-780-2229

Provider Taxonomy Codes

  • Taxonomy code: 310400000X , with the licence number:  AL601304298 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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