Basic Information
| Provider Information | |||||||||
| NPI: | 1588722300 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | CENTER FOR FAMILY HEALTH | ||||||||
| LastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 505 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011266 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177485500 | ||||||||
| FaxNumber: | 5177832728 | ||||||||
| Practice Location | |||||||||
| Address1: | 500 N JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | JACKSON | ||||||||
| State: | MI | ||||||||
| PostalCode: | 492011223 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5177485500 | ||||||||
| FaxNumber: | 5177809286 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2006 | ||||||||
| LastUpdateDate: | 02/10/2022 | ||||||||
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| AuthorizedOfficialLastName: | MAYO | ||||||||
| AuthorizedOfficialFirstName: | MICHELLE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | MANAGER | ||||||||
| AuthorizedOfficialTelephone: | 5177485500 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | Y | ||||||||
| ParentOrganizationLBN: | CENTER FOR FAMILY HEALTH | ||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 02/10/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 1223D0001X | 2901008781 | MI | N | 193400000X SINGLE SPECIALTY GROUP | Dental Providers | Dentist | Dental Public Health | 261QF0400X | Y | Ambulatory Health Care Facilities | Clinic/Center | Federally Qualified Health Center (FQHC) |
No ID Information.