# SEDARA MAE HEALTHCARE CLINIC, LLC

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- **Entity:** Organization
- **Status:** Active
- **Organization subpart:** No

## Provider details

- **NPI number:** 1265875892
- **Authorized official:** MRS. LISA M LUCAS MSN, APRN-BC (PRACTITIONER)
- **Authorized official phone:** (800) 363-4661

## Contact information

- **Practice address:** 1167 MADISON AVE SE, MAILBOX 5, GRAND RAPIDS, MI 49507-1200
- **Practice address phone:** (616) 301-1020
- **Mailing address:** PO BOX 8862, KENTWOOD, MI 49518-8862
- **Mailing address phone:** (616) 301-1020

## Taxonomy

| Code | Description | License number | State | Primary |
| --- | --- | --- | --- | --- |
| 261QC1500X | Community Health Clinic/Center | 4704237090 | MI | Yes |

## Other

- **Enumeration date:** 04/12/2013
- **Last updated:** 04/25/2013