Basic Information
| Provider Information | |||||||||
| NPI: | 1366790586 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | COUNTY OF GENESEE | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| OtherOrganizationName: | GENESEE COMMUNITY HEALTH CENTER-CENTER CITY | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 725 MASON ST | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573736 | ||||||||
| FaxNumber: | 8102573785 | ||||||||
| Practice Location | |||||||||
| Address1: | 725 MASON ST | ||||||||
| Address2: | |||||||||
| City: | FLINT | ||||||||
| State: | MI | ||||||||
| PostalCode: | 485032421 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8102573736 | ||||||||
| FaxNumber: | 8102573785 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 08/20/2012 | ||||||||
| LastUpdateDate: | 11/27/2012 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| AuthorizedOfficialLastName: | LAWTHER | ||||||||
| AuthorizedOfficialFirstName: | TIM | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 8102573707 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | GENESEE COUNTY COMMUNITY MENTAL HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MR. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
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.