Provider Demographics
NPI:1497368187
Name:LARIVE, STACIA NICHOLE
Entity Type:Individual
Prefix:
First Name:STACIA
Middle Name:NICHOLE
Last Name:LARIVE
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 1:105 VINE ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601-2435
Mailing Address - Country:US
Mailing Address - Phone:231-884-1988
Mailing Address - Fax:
Practice Address - Street 1:105 VINE ST
Practice Address - Street 2:
Practice Address - City:CADILLAC
Practice Address - State:MI
Practice Address - Zip Code:49601-2435
Practice Address - Country:US
Practice Address - Phone:231-884-1988
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-08-24
Last Update Date:2020-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF830403510311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home