Provider Demographics
NPI:1639687213
Name:EASTERN GROUPHOME
Entity Type:Organization
Organization Name:EASTERN GROUPHOME
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWENER
Authorized Official - Prefix:
Authorized Official - First Name:AMANUEL
Authorized Official - Middle Name:
Authorized Official - Last Name:ASFAHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-516-3888
Mailing Address - Street 1:5770 EASTERN AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49508-6281
Mailing Address - Country:US
Mailing Address - Phone:616-516-3888
Mailing Address - Fax:
Practice Address - Street 1:5770 EASTERN AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49508-6281
Practice Address - Country:US
Practice Address - Phone:616-516-3888
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-01-17
Last Update Date:2018-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251T00000XAgenciesProgram of All-Inclusive Care for the Elderly (PACE) Provider Organization