Provider Demographics
NPI:1689102931
Name:JERRY'S DREAM ADULT HOMES
Entity Type:Organization
Organization Name:JERRY'S DREAM ADULT HOMES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VICKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:RUNYON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-293-7198
Mailing Address - Street 1:PO BOX 1086
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49501-1086
Mailing Address - Country:US
Mailing Address - Phone:616-293-7198
Mailing Address - Fax:
Practice Address - Street 1:1124 W LEONARD CT NW
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49534-6835
Practice Address - Country:US
Practice Address - Phone:616-735-4681
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-05-31
Last Update Date:2017-05-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS410269764311ZA0620X
MIAS410269763311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1174395Medicaid
MI9493156Medicaid