Provider Demographics
NPI:1134969447
Name:SUCO, MELISSA
Entity type:Individual
Prefix:
First Name:MELISSA
Middle Name:
Last Name:SUCO
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:PO BOX 603
Mailing Address - Street 2:
Mailing Address - City:LESLIE
Mailing Address - State:MI
Mailing Address - Zip Code:49251-0603
Mailing Address - Country:US
Mailing Address - Phone:517-589-9118
Mailing Address - Fax:
Practice Address - Street 1:3680 CHURCHILL RD
Practice Address - Street 2:
Practice Address - City:LESLIE
Practice Address - State:MI
Practice Address - Zip Code:49251-9550
Practice Address - Country:US
Practice Address - Phone:517-589-9118
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-27
Last Update Date:2024-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS330397180311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home