Organization
JERRY'S DREAM ADULT HOMES
Active
Organization subpart
No
Provider details
NPI number
Authorized official
VICKIE RUNYON (OWNER)
(616) 293-7198
Entity
Organization
Contact information
Practice address
1124 W LEONARD CT NW, GRAND RAPIDS, MI 49534-6835
(616) 735-4681
Mailing address
PO BOX 1086, GRAND RAPIDS, MI 49501-1086
(616) 293-7198
Taxonomy
Speciality
Code
Description
License number
State
311ZA0620X
Adult Care Home Facility
AS410269763
MI
311ZA0620X
Adult Care Home Facility
Primary
AS410269764
MI
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
1174395
—
MI
05
—
9493156
—
MI
Enumeration date
05/31/2017
Last updated
05/31/2017
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