1427514306 NPI number — ELDER CARE OF WEST MICHIGAN PLLC

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 1427514306 NPI number — ELDER CARE OF WEST MICHIGAN PLLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ELDER CARE OF WEST MICHIGAN PLLC
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:
1427514306
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
05/02/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4448 KOINONIA DR NE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAND RAPIDS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49525-9332
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6785 MYERS LAKE AVE NE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
ROCKFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49341-7416
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
616-366-4234
Provider Business Practice Location Address Fax Number:
616-469-1118
Provider Enumeration Date:
02/15/2019

Additional Information

Authorized Official

Authorized Official Last Name:
UECKER
Authorized Official First Name:
KATHY JO
Authorized Official Middle Name:
Authorized Official Title or Position:
BUSINESS MANAGER
Authorized Official Telephone Number:
269-420-9404

Provider Taxonomy Codes

  • Taxonomy code: 363LG0600X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207QG0300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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