Basic Information
| Provider Information | |||||||||
| NPI: | 1578073391 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALCONA CITIZENS FOR HEALTH, INC. | ||||||||
| LastName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | AHC OSCODA AREA HIGH SCHOOL | ||||||||
| OtherOrganizationType: | 3 | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 655 | ||||||||
| Address2: | |||||||||
| City: | ALPENA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497070655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897369815 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3550 E RIVER RD | ||||||||
| Address2: | |||||||||
| City: | OSCODA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 487509025 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9897399121 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/06/2017 | ||||||||
| LastUpdateDate: | 10/06/2017 | ||||||||
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| AuthorizedOfficialLastName: | BAUMGARDNER | ||||||||
| AuthorizedOfficialFirstName: | CHRISTINE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | CEO | ||||||||
| AuthorizedOfficialTelephone: | 9893580673 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | ALCONA CITIZENS FOR HEALTH, INC. | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1041S0200X | Y | 193400000X SINGLE SPECIALTY GROUP | Behavioral Health & Social Service Providers | Social Worker | School |
ID Information
| ID | Type | State | Issuer | Description | 1326055450 | 05 | MI | MEDICAID |