Provider Demographics
NPI:1780076059
Name:CARTER, MARY JAN
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:JAN
Last Name:CARTER
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 1:17570 S RIVER RD
Mailing Address - Street 2:
Mailing Address - City:THREE RIVERS
Mailing Address - State:MI
Mailing Address - Zip Code:49093-9323
Mailing Address - Country:US
Mailing Address - Phone:269-873-0399
Mailing Address - Fax:
Practice Address - Street 1:17570 S RIVER RD
Practice Address - Street 2:
Practice Address - City:THREE RIVERS
Practice Address - State:MI
Practice Address - Zip Code:49093-9323
Practice Address - Country:US
Practice Address - Phone:708-600-5845
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-02-24
Last Update Date:2015-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X251E00000X
251E00000X, 372600000X, 374U00000X
MI472761843376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes251E00000XAgenciesHome Health
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty
No374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty
No376J00000XNursing Service Related ProvidersHomemakerGroup - Single Specialty