Basic Information
| Provider Information | |||||||||
| NPI: | 1336701119 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | INTERCARE COMMUNITY HEALTH NETWORK | ||||||||
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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: | 7450 HOCHBERGER RD RM 15A | ||||||||
| Address2: | |||||||||
| City: | EAU CLAIRE | ||||||||
| State: | MI | ||||||||
| PostalCode: | 491119762 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2694616947 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2019 | ||||||||
| LastUpdateDate: | 07/02/2019 | ||||||||
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| AuthorizedOfficialLastName: | HENDERSHOTT | ||||||||
| AuthorizedOfficialFirstName: | VELMA | ||||||||
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| AuthorizedOfficialTitleorPosition: | CEO/PRESIDENT | ||||||||
| AuthorizedOfficialTelephone: | 2694277937 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YS0200X | N | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Counselor | School | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.