Basic Information
| Provider Information | |||||||||
| NPI: | 1134491731 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | CRYSTAL LAKE CLINIC PC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 6227 FRANKFORT HWY | ||||||||
| Address2: | |||||||||
| City: | BENZONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496168632 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318829661 | ||||||||
| FaxNumber: | 2318829616 | ||||||||
| Practice Location | |||||||||
| Address1: | 1806 E PARKDALE AVE STE 2 | ||||||||
| Address2: | |||||||||
| City: | MANISTEE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 496609364 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2318829661 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2012 | ||||||||
| LastUpdateDate: | 01/30/2012 | ||||||||
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| AuthorizedOfficialLastName: | NIELSEN | ||||||||
| AuthorizedOfficialFirstName: | RICHARD | ||||||||
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| AuthorizedOfficialTitleorPosition: | PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2318829661 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialCredential: | M.D. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207Q00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Family Medicine |
No ID Information.