Provider Demographics
NPI:1093189219
Name:RICHARDS, CAROL (LPN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:
Last Name:RICHARDS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1490 E BELTLINE AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49506-4336
Mailing Address - Country:US
Mailing Address - Phone:616-278-7367
Mailing Address - Fax:
Practice Address - Street 1:1490 E BELTLINE AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49506-4336
Practice Address - Country:US
Practice Address - Phone:616-278-7367
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-11-26
Last Update Date:2023-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703109087311ZA0620X, 164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home