Provider Demographics
NPI:1336463215
Name:CANDACE MATHEWS
Entity Type:Organization
Organization Name:CANDACE MATHEWS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARENT
Authorized Official - Prefix:
Authorized Official - First Name:CANDACE
Authorized Official - Middle Name:RENEE
Authorized Official - Last Name:MATHEWS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:517-795-1752
Mailing Address - Street 1:117 E ADDISON ST
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49203-4301
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:117 E ADDISON ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49203-4301
Practice Address - Country:US
Practice Address - Phone:517-795-1752
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-03-21
Last Update Date:2010-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI385H00000X385H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care