Basic Information
| Provider Information | |||||||||
| NPI: | 1023250412 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | WESTERN WAYNE FAMILY HEALTH CENTERS | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | |||||||||
| OtherOrganizationName: | WESTERN WAYNE FAMILY HEALTH CENTERS - TAYLOR | ||||||||
| OtherOrganizationType: | 5 | ||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 26650 EUREKA RD | ||||||||
| Address2: | SUITE C-1 | ||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481804835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349414991 | ||||||||
| FaxNumber: | 7349414919 | ||||||||
| Practice Location | |||||||||
| Address1: | 26650 EUREKA RD | ||||||||
| Address2: | SUITE C-1 | ||||||||
| City: | TAYLOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 481804835 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7349414991 | ||||||||
| FaxNumber: | 7349414919 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/31/2009 | ||||||||
| LastUpdateDate: | 01/20/2011 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | ATKINS | ||||||||
| AuthorizedOfficialFirstName: | LINDA | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 7349414991 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | WESTERN WAYNE FAMILY HEALTH CENTERS | ||||||||
| AuthorizedOfficialNamePrefix: | MS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | MI | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
ID Information
| ID | Type | State | Issuer | Description | 700H249990 | 01 | BCBSM | OTHER | 500H249980 | 01 | MI | BCBS | OTHER | 1023250412 | 05 | MI | MEDICAID |