Provider Demographics
NPI:1598445124
Name:KOZA, MARCIA LUCILLE
Entity Type:Individual
Prefix:
First Name:MARCIA
Middle Name:LUCILLE
Last Name:KOZA
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 1:12955 68TH ST SE
Mailing Address - Street 2:
Mailing Address - City:ALTO
Mailing Address - State:MI
Mailing Address - Zip Code:49302
Mailing Address - Country:US
Mailing Address - Phone:616-868-0001
Mailing Address - Fax:616-868-0030
Practice Address - Street 1:12955 68TH ST SE
Practice Address - Street 2:
Practice Address - City:ALTO
Practice Address - State:MI
Practice Address - Zip Code:49302
Practice Address - Country:US
Practice Address - Phone:616-868-0001
Practice Address - Fax:616-868-0030
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAM410416004311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home