1902136385 NPI number — GREAT LAKES BAY HEALTH CENTERS

Table of content: (NPI 1902136385)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1902136385 NPI number — GREAT LAKES BAY HEALTH CENTERS

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
GREAT LAKES BAY HEALTH CENTERS
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:
6
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:
1902136385
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/22/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
501 LAPEER
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAGINAW
Provider Business Mailing Address State Name:
MI
Provider Business Mailing Address Postal Code:
48607-1208
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
989-759-6464
Provider Business Mailing Address Fax Number:
989-399-8233

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1015 COMMERCE DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
VASSAR
Provider Business Practice Location Address State Name:
MI
Provider Business Practice Location Address Postal Code:
48768-9589
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
989-823-3010
Provider Business Practice Location Address Fax Number:
989-823-9243
Provider Enumeration Date:
01/06/2010

Additional Information

Authorized Official

Authorized Official Last Name:
GALONASKA
Authorized Official First Name:
LISA
Authorized Official Middle Name:
Authorized Official Title or Position:
VICE PRESIDENT
Authorized Official Telephone Number:
989-759-6464

Provider Taxonomy Codes

  • Taxonomy code: 261QF0400X , 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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