Basic Information
| Provider Information | |||||||||
| NPI: | 1003914946 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | COUNTY OF MUSKEGON | ||||||||
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| Mailing Information | |||||||||
| Address1: | 376 E APPLE AVE | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494423466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317241111 | ||||||||
| FaxNumber: | 2317244188 | ||||||||
| Practice Location | |||||||||
| Address1: | 376 E APPLE AVENUE | ||||||||
| Address2: | |||||||||
| City: | MUSKEGON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 494423466 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2317241111 | ||||||||
| FaxNumber: | 2317244188 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/21/2006 | ||||||||
| LastUpdateDate: | 09/08/2014 | ||||||||
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| AuthorizedOfficialLastName: | RUPP | ||||||||
| AuthorizedOfficialFirstName: | JULIA | ||||||||
| AuthorizedOfficialMiddleName: | B | ||||||||
| AuthorizedOfficialTitleorPosition: | EXECUTIVE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2317241111 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 4355890 | 05 | MI | MEDICAID | 750910792 | 01 | MI | BLUE CROSS APPLE AVE | OTHER | 1712452 | 05 | MI | MEDICAID |