Provider Demographics
NPI:1982964144
Name:M.O.M
Entity Type:Organization
Organization Name:M.O.M
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CERTIFIED NURSE AIDE
Authorized Official - Prefix:MRS
Authorized Official - First Name:SYLVIA
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DUFLO
Authorized Official - Suffix:
Authorized Official - Credentials:CNA
Authorized Official - Phone:616-594-4465
Mailing Address - Street 1:9276 MONROE RD
Mailing Address - Street 2:
Mailing Address - City:LAKE
Mailing Address - State:MI
Mailing Address - Zip Code:48632-9108
Mailing Address - Country:US
Mailing Address - Phone:616-594-4465
Mailing Address - Fax:
Practice Address - Street 1:9276 MONROE RD
Practice Address - Street 2:
Practice Address - City:LAKE
Practice Address - State:MI
Practice Address - Zip Code:48632-9108
Practice Address - Country:US
Practice Address - Phone:616-594-4465
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-22
Last Update Date:2012-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI230006976540402251J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251J00000XAgenciesNursing Care