Ivy Lane Residence LLC

Primary specialty

Adult Care Home FacilityTaxonomy code 311ZA0620X

Legal business name

IVY LANE RESIDENCE LLC

Practice address

4897 Grenadier Dr SW
Wyoming, MI 49509-5021

Phone

(612) 232-5643

NPI assigned

Dec 18, 2023

Organization subpart

No

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name

Najib Moalin

Title

Director

Phone

(612) 232-5643

Specialties & licenses 1

Addresses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1702857600000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1702857600000",
    "number": "1679341770",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4897 GRENADIER DR SW",
            "city": "WYOMING",
            "state": "MI",
            "postal_code": "495095021"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4897 GRENADIER DR SW",
            "city": "WYOMING",
            "state": "MI",
            "postal_code": "495095021",
            "telephone_number": "612-232-5643"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "IVY LANE RESIDENCE LLC",
        "organizational_subpart": "NO",
        "enumeration_date": "2023-12-18",
        "last_updated": "2023-12-18",
        "certification_date": "2023-12-18",
        "status": "A",
        "authorized_official_last_name": "MOALIN",
        "authorized_official_first_name": "NAJIB",
        "authorized_official_title_or_position": "DIRECTOR",
        "authorized_official_telephone_number": "612-232-5643"
    },
    "taxonomies": [
        {
            "code": "311ZA0620X",
            "taxonomy_group": "",
            "desc": "Custodial Care Facility, Adult Care Home",
            "state": null,
            "license": null,
            "primary": true
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

• Megan Joy Ipema, FNP, DNP
• Brad Alan Irving, DO
• Karen Marie Irving, LBSW
• Breanne Israwi, PT
• Yolanda Ivens, MSMHC
• Uzoma Iwuagwu
• Katie Jacklin
• Annie Jackson, OTR/L
• Kelsi M Jackson
• Rebecca Jacobi, PHARMD

• Adult Care Home Facility in Wyoming, MI
• Providers in Wyoming, MI by specialty
• Adult Care Home Facility in Michigan

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Dec 18, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.