1689796930 NPI number — CHIPPEWA COUNTY HEALTH DEPARTMENT

Table of content: (NPI 1689796930)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1689796930 NPI number — CHIPPEWA COUNTY HEALTH DEPARTMENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CHIPPEWA COUNTY HEALTH DEPARTMENT
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:
SAULT HIGH ADOLESCENT CARE CENTER (SHACC)
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:
1689796930
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
02/26/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
508 ASHMUN ST STE 120
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAULT SAINTE MARIE
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49783-1976
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-635-1568
Provider Business Mailing Address Fax Number:
906-253-1466

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
904 MARQUETTE AVE
Provider Second Line Business Practice Location Address:
ROOM 622
Provider Business Practice Location Address City Name:
SAULT SAINTE MARIE
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49783-3301
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-632-5690
Provider Business Practice Location Address Fax Number:
906-635-1325
Provider Enumeration Date:
04/06/2007

Additional Information

Authorized Official

Authorized Official Last Name:
SENKUS
Authorized Official First Name:
KAREN
Authorized Official Middle Name:
MARIE
Authorized Official Title or Position:
HEALTH OFFICER
Authorized Official Telephone Number:
906-253-3103

Provider Taxonomy Codes

  • Taxonomy code: 261QD0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QM0855X , with the licence number: 6301008585 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QP2300X , with the licence number: 4301030101 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QS1000X , with the licence number: 4301030101 , 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: 4905013 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4905004 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 680A710440 . This is a "BCBS-MENTAL HEALTH" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4904983 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 500A710530 . This is a "BCBS-NP GROUP" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 4904992 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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