1518957208 NPI number — MANISTEE BENZIE CMH

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1518957208 NPI number — MANISTEE BENZIE CMH

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
MANISTEE BENZIE CMH
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:
Provider Other Organization Name Type Code:
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:
1518957208
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/22/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
310 GLOCHESKI DR
Provider Second Line Business Mailing Address:
PO BOX 335
Provider Business Mailing Address City Name:
MANISTEE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49660-2639
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
877-398-2013
Provider Business Mailing Address Fax Number:
231-723-1504

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
6051 FRANKFORT HWY
Provider Second Line Business Practice Location Address:
SUITE 200
Provider Business Practice Location Address City Name:
BENZONIA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49616-9558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
877-398-2013
Provider Business Practice Location Address Fax Number:
231-882-2195
Provider Enumeration Date:
10/25/2005

Additional Information

Authorized Official

Authorized Official Last Name:
NIEMAN
Authorized Official First Name:
DONNA
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCE OFFICER
Authorized Official Telephone Number:
877-398-2013

Provider Taxonomy Codes

  • Taxonomy code: 251S00000X , 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: 1705304 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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