Provider Demographics
NPI:1780399287
Name:ADIA LLC
Entity type:Organization
Organization Name:ADIA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:LICENSEE
Authorized Official - Prefix:
Authorized Official - First Name:BEATA
Authorized Official - Middle Name:
Authorized Official - Last Name:MPESHA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-856-0163
Mailing Address - Street 1:3981 WEDGEWOOD DR SW
Mailing Address - Street 2:
Mailing Address - City:WYOMING
Mailing Address - State:MI
Mailing Address - Zip Code:49519-3137
Mailing Address - Country:US
Mailing Address - Phone:616-734-6194
Mailing Address - Fax:
Practice Address - Street 1:3981 WEDGEWOOD DR SW
Practice Address - Street 2:
Practice Address - City:WYOMING
Practice Address - State:MI
Practice Address - Zip Code:49519-3137
Practice Address - Country:US
Practice Address - Phone:616-734-6194
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-18
Last Update Date:2023-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI933217Medicaid