Basic Information
| Provider Information | |||||||||
| NPI: | 1205363033 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INTERCARE COMMUNITY HEALTH NETWORK | ||||||||
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| OtherOrganizationName: | INTERCARE WOMEN'S HEALTH CENTER | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 50 INDUSTRIAL PARK RD | ||||||||
| Address2: | |||||||||
| City: | BANGOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490131246 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694277937 | ||||||||
| FaxNumber: | 2694275180 | ||||||||
| Practice Location | |||||||||
| Address1: | 796 HIGHWAY M-139 | ||||||||
| Address2: | |||||||||
| City: | BENTON HARBOR | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490223881 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8558696900 | ||||||||
| FaxNumber: | 2699274208 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/11/2017 | ||||||||
| LastUpdateDate: | 05/11/2017 | ||||||||
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| AuthorizedOfficialLastName: | HENDERRSHOTT | ||||||||
| AuthorizedOfficialFirstName: | VELMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 2694277937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.