Provider Demographics
NPI:1053837922
Name:MCMILLIAN, RAEKESHA LACHELLE
Entity Type:Individual
Prefix:
First Name:RAEKESHA
Middle Name:LACHELLE
Last Name:MCMILLIAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1232 KALAMAZOO AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49507-1923
Mailing Address - Country:US
Mailing Address - Phone:616-427-4570
Mailing Address - Fax:
Practice Address - Street 1:820 WATKINS ST SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-1345
Practice Address - Country:US
Practice Address - Phone:616-427-4570
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-22
Last Update Date:2017-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS4103885383104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
MIW314730488684Medicaid