Provider Demographics
NPI:1366657744
Name:AEGIN PLACE OF WEST MICHIGAN
Entity Type:Organization
Organization Name:AEGIN PLACE OF WEST MICHIGAN
Other - Org Name:AEGIN PLACE OF WEST MICHIGAN LLC
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:OWNER/CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:LANCE
Authorized Official - Middle Name:
Authorized Official - Last Name:GRAGG
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-375-5356
Mailing Address - Street 1:333 W. WESTERN AVE STE 209
Mailing Address - Street 2:
Mailing Address - City:MUSKEGON
Mailing Address - State:MI
Mailing Address - Zip Code:49440
Mailing Address - Country:US
Mailing Address - Phone:231-375-5356
Mailing Address - Fax:231-756-7211
Practice Address - Street 1:333 W. WESTERN AVE STE 209
Practice Address - Street 2:
Practice Address - City:MUSKEGON
Practice Address - State:MI
Practice Address - Zip Code:49440
Practice Address - Country:US
Practice Address - Phone:231-375-5356
Practice Address - Fax:231-756-7211
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-05-11
Last Update Date:2020-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes253Z00000XAgenciesIn Home Supportive Care
No101Y00000XBehavioral Health & Social Service ProvidersCounselorGroup - Multi-Specialty