Provider Demographics
NPI:1881961498
Name:THE MEADOWS SPECIALIZED RESIDENTIAL PROGRAM
Entity type:Organization
Organization Name:THE MEADOWS SPECIALIZED RESIDENTIAL PROGRAM
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/HOME ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:GINA
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:KELLY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-496-1033
Mailing Address - Street 1:55377 WALTERSPAUGH RD
Mailing Address - Street 2:
Mailing Address - City:MENDON
Mailing Address - State:MI
Mailing Address - Zip Code:49072-9545
Mailing Address - Country:US
Mailing Address - Phone:269-496-1033
Mailing Address - Fax:
Practice Address - Street 1:55377 WALTERSPAUGH RD
Practice Address - Street 2:
Practice Address - City:MENDON
Practice Address - State:MI
Practice Address - Zip Code:49072-9545
Practice Address - Country:US
Practice Address - Phone:269-496-1033
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-27
Last Update Date:2011-11-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAS750239107323P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes323P00000XResidential Treatment FacilitiesPsychiatric Residential Treatment Facility