Basic Information
Provider Information | |||||||||
NPI: | 1538463914 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | HOPE NETWORK | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1492 E BELTLINE AVE SE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495064336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6169400040 | ||||||||
FaxNumber: | 6169401055 | ||||||||
Practice Location | |||||||||
Address1: | 1492 E BELTLINE AVE SE | ||||||||
Address2: |   | ||||||||
City: | GRAND RAPIDS | ||||||||
State: | MI | ||||||||
PostalCode: | 495064336 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6169400040 | ||||||||
FaxNumber: | 6169401055 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 12/29/2010 | ||||||||
LastUpdateDate: | 12/29/2010 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | KRZCIOK | ||||||||
AuthorizedOfficialFirstName: | LORI | ||||||||
AuthorizedOfficialMiddleName: | JO | ||||||||
AuthorizedOfficialTitleorPosition: | PROGRAM NURSE | ||||||||
AuthorizedOfficialTelephone: | 6169400040 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: | MISS | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | LPN | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 323P00000X | 4703093649 | MI | Y |   | Residential Treatment Facilities | Psychiatric Residential Treatment Facility |   |
No ID Information.