1689796930 NPI number — CHIPPEWA COUNTY HEALTH DEPARTMENT

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 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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