1174670459 NPI number — COUNTY OF GRAND TRAVERSE

Table of content: (NPI 1174670459)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1174670459 NPI number — COUNTY OF GRAND TRAVERSE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
COUNTY OF GRAND TRAVERSE
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:
GRAND TRAVERSE COUNTY HEALTH DEPARTMENT
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:
1174670459
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/12/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2600 LAFRANIER RD STE A
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
TRAVERSE CITY
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49686-4765
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
231-995-6111
Provider Business Mailing Address Fax Number:
231-995-6109

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2600 LAFRANIER RD STE A
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
TRAVERSE CITY
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49686-4765
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
231-995-6111
Provider Business Practice Location Address Fax Number:
231-995-6109
Provider Enumeration Date:
01/05/2007

Additional Information

Authorized Official

Authorized Official Last Name:
CARLSON
Authorized Official First Name:
ERIN
Authorized Official Middle Name:
Authorized Official Title or Position:
ACCOUNTANT
Authorized Official Telephone Number:
231-995-6103

Provider Taxonomy Codes

  • Taxonomy code: 251K00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 261Q00000X , with the licence number: 4301028725 , registered in the state of MI ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

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

  • Identifier: 772813923 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 235100410 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 773054097 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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