Provider Demographics
NPI:1811771488
Name:POWELL HOUSE AFC
Entity type:Organization
Organization Name:POWELL HOUSE AFC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LORI
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTANZA
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:269-983-0300
Mailing Address - Street 1:3838 NILES RD
Mailing Address - Street 2:
Mailing Address - City:SAINT JOSEPH
Mailing Address - State:MI
Mailing Address - Zip Code:49085-8612
Mailing Address - Country:US
Mailing Address - Phone:126-998-3030
Mailing Address - Fax:
Practice Address - Street 1:3531 NILES RD
Practice Address - Street 2:
Practice Address - City:SAINT JOSEPH
Practice Address - State:MI
Practice Address - Zip Code:49085-8744
Practice Address - Country:US
Practice Address - Phone:269-281-0034
Practice Address - Fax:269-983-0303
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-08-23
Last Update Date:2023-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home