1548464951 NPI number — GREAT LAKES BAY HEALTH CENTERS

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 1548464951 NPI number — GREAT LAKES BAY HEALTH CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES BAY HEALTH CENTERS
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:
GREAT LAKES BAY HEALTH CENTERS MANCHESTER
Provider Other Organization Name Type Code:
5
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:
1548464951
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/19/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 LAPEER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48607-1208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-759-6464
Provider Business Mailing Address Fax Number:
989-399-8233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4800 ESCH ROAD
Provider Second Line Business Practice Location Address:
MANCHESTER MIGRANT CAMP
Provider Business Practice Location Address City Name:
MANCHESTER
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48158
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-759-6464
Provider Business Practice Location Address Fax Number:
989-399-8233
Provider Enumeration Date:
06/12/2007

Additional Information

Authorized Official

Authorized Official Last Name:
GALONASKA
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
989-759-6464

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , 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: 0G36111 . This is a "0G36111 MEDICARE BILL PAY TO" identifier . This identifiers is of the category "OTHER".




Copyright © 2007-2024 www.npivalidator.com