1053635359 NPI number — PENNOCK HOSPITAL BOARD OF TRUSTEES

Table of content: (NPI 1053635359)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1053635359 NPI number — PENNOCK HOSPITAL BOARD OF TRUSTEES

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PENNOCK HOSPITAL BOARD OF TRUSTEES
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:
PENNOCK HOSPITAL LAKE ODESSA SAT LAB
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:
1053635359
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
03/11/2013
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1009 W GREEN ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
HASTINGS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49058-1710
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
269-945-1212
Provider Business Mailing Address Fax Number:
269-948-3117

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4294 LAUREL DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE ODESSA
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48849-8430
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
269-945-1212
Provider Business Practice Location Address Fax Number:
616-674-1698
Provider Enumeration Date:
03/16/2010

Additional Information

Authorized Official

Authorized Official Last Name:
SALISBURY
Authorized Official First Name:
THOMAS
Authorized Official Middle Name:
Authorized Official Title or Position:
FINANCE DIRECTOR
Authorized Official Telephone Number:
269-945-1212

Provider Taxonomy Codes

  • Taxonomy code: 282N00000X , 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)





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