Provider Demographics
NPI:1730616509
Name:EVERGREEN MEADOW AFC
Entity type:Organization
Organization Name:EVERGREEN MEADOW AFC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AFC OPERATOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:ERDMAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-682-0848
Mailing Address - Street 1:1944 BUTTRICK AVE SE
Mailing Address - Street 2:
Mailing Address - City:ADA
Mailing Address - State:MI
Mailing Address - Zip Code:49301-9204
Mailing Address - Country:US
Mailing Address - Phone:616-682-0848
Mailing Address - Fax:
Practice Address - Street 1:1944 BUTTRICK AVE SE
Practice Address - Street 2:
Practice Address - City:ADA
Practice Address - State:MI
Practice Address - Zip Code:49301-9204
Practice Address - Country:US
Practice Address - Phone:616-682-0848
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-11
Last Update Date:2017-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF410255092311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home