1730186891 NPI number — PINECREST MEDICAL CARE FACILITY

Table of content: (NPI 1730186891)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1730186891 NPI number — PINECREST MEDICAL CARE FACILITY

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
PINECREST MEDICAL CARE FACILITY
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:
Provider Other Organization Name Type Code:
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:
1730186891
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/20/2025
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 603
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
POWERS
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
49874-0603
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
906-497-5244
Provider Business Mailing Address Fax Number:
906-497-5005

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
N15995 MAIN ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
POWERS
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
49874-9608
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
906-497-5244
Provider Business Practice Location Address Fax Number:
906-497-5005
Provider Enumeration Date:
07/05/2005

Additional Information

Authorized Official

Authorized Official Last Name:
MAPES
Authorized Official First Name:
RICHARD
Authorized Official Middle Name:
Authorized Official Title or Position:
ADMINISTRATOR
Authorized Official Telephone Number:
906-497-5244

Provider Taxonomy Codes

  • Taxonomy code: 261QR0401X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 314000000X , with the licence number: 558510 , 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: 30413 . This is a "BCBSM PROVIDER NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 09623 . This is a "BCBSM PROVIDER ID NUMBER" identifier , issued by the state of ( MI ) . This identifiers is of the category "OTHER".
  • Identifier: 61 2085277 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".
  • Identifier: 64 2085277 , issued by the state of ( MI ) . This identifiers is of the category "MEDICAID".




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