Basic Information
| Provider Information | |||||||||
| NPI: | 1073661484 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COMMUNITY HEALTH CENTER OF BRANCH COUNTY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | CHC PEDIATRIC AND ADOLESCENT CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 274 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490362041 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795400 | ||||||||
| FaxNumber: | 5172795352 | ||||||||
| Practice Location | |||||||||
| Address1: | 358 E CHICAGO ST | ||||||||
| Address2: | |||||||||
| City: | COLDWATER | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490362072 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5172795252 | ||||||||
| FaxNumber: | 5172795253 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/08/2007 | ||||||||
| LastUpdateDate: | 09/07/2012 | ||||||||
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| AuthorizedOfficialLastName: | DEGROOT | ||||||||
| AuthorizedOfficialFirstName: | RANDALL (RANDY) | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 5172795489 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR1300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Rural Health |
ID Information
| ID | Type | State | Issuer | Description | 238615 | 01 | MEDICARE RHC PROVIDER NUMBER | OTHER |