1013013275 NPI number — CANTERBURY HEALTH CARE, INC

Table of content: (NPI 1013013275)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1013013275 NPI number — CANTERBURY HEALTH CARE, INC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CANTERBURY HEALTH CARE, INC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
CANTERBURY ON-THE-LAKE
Provider Other Organization Name Type Code:
3
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1013013275
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
5601 HATCHERY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WATERFORD
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48329-3451
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
248-674-9292
Provider Business Mailing Address Fax Number:
248-674-5393

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5601 HATCHERY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WATERFORD
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48329
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
248-674-9292
Provider Business Practice Location Address Fax Number:
248-674-5393
Provider Enumeration Date:
09/15/2006

Additional Information

Authorized Official

Authorized Official Last Name:
DRUTCHAS
Authorized Official First Name:
CHERYL
Authorized Official Middle Name:
A
Authorized Official Title or Position:
CHAIRMAN
Authorized Official Telephone Number:
248-674-9292

Provider Taxonomy Codes

  • Taxonomy code: 314000000X , with the licence number:  1070000051 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 60 2083058 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 09755 . This is a "BLUE CROSS/ BLUE SHIELD M" identifier . This identifiers is of the category "OTHER".
  • Identifier: F0000008663 . This is a "BLUE CARE NETWORK" identifier . This identifiers is of the category "OTHER".




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