Provider Demographics
NPI:1588918841
Name:BOOKER, EDWARD A JR
Entity type:Individual
Prefix:MR
First Name:EDWARD
Middle Name:A
Last Name:BOOKER
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 JUNIPER AVE
Mailing Address - Street 2:
Mailing Address - City:HOLLAND
Mailing Address - State:MI
Mailing Address - Zip Code:49424-8246
Mailing Address - Country:US
Mailing Address - Phone:616-886-6917
Mailing Address - Fax:
Practice Address - Street 1:1740 WILLARD AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49507-2662
Practice Address - Country:US
Practice Address - Phone:616-886-6917
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-11-07
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI410376324500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes324500000XResidential Treatment FacilitiesSubstance Abuse Rehabilitation Facility