Provider Demographics
NPI:1417706748
Name:HART, MARCIE LEE
Entity type:Individual
Prefix:
First Name:MARCIE
Middle Name:LEE
Last Name:HART
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7774 DICKERSON LAKE RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MI
Mailing Address - Zip Code:48838-9241
Mailing Address - Country:US
Mailing Address - Phone:616-894-0660
Mailing Address - Fax:
Practice Address - Street 1:7774 DICKERSON LAKE RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MI
Practice Address - Zip Code:48838-9241
Practice Address - Country:US
Practice Address - Phone:616-894-0660
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-17
Last Update Date:2024-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAF590310562311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home