Provider Demographics
NPI:1790143279
Name:ADVANCED ADULT FOSTER CARE, INC.
Entity Type:Organization
Organization Name:ADVANCED ADULT FOSTER CARE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:WAYNE
Authorized Official - Last Name:MINIAT
Authorized Official - Suffix:
Authorized Official - Credentials:MI, DD
Authorized Official - Phone:269-760-9692
Mailing Address - Street 1:PO BOX 371
Mailing Address - Street 2:
Mailing Address - City:PAW PAW
Mailing Address - State:MI
Mailing Address - Zip Code:49079-0371
Mailing Address - Country:US
Mailing Address - Phone:269-674-3051
Mailing Address - Fax:269-674-3051
Practice Address - Street 1:202 CORWIN MEADOWS DR
Practice Address - Street 2:
Practice Address - City:LAWRENCE
Practice Address - State:MI
Practice Address - Zip Code:49064-9548
Practice Address - Country:US
Practice Address - Phone:269-674-3051
Practice Address - Fax:269-674-3051
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-29
Last Update Date:2016-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS800315037320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities