Basic Information
| Provider Information | |||||||||
| NPI: | 1649733148 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | HARBOR HALL, INC. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 704 EMMET ST | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702910 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313475511 | ||||||||
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| Practice Location | |||||||||
| Address1: | 114 RUSH ST | ||||||||
| Address2: | |||||||||
| City: | PETOSKEY | ||||||||
| State: | MI | ||||||||
| PostalCode: | 497702920 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2313475511 | ||||||||
| FaxNumber: | 2313475422 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/11/2019 | ||||||||
| LastUpdateDate: | 01/21/2021 | ||||||||
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| AuthorizedOfficialLastName: | PENNINGTON | ||||||||
| AuthorizedOfficialFirstName: | KAYLA | ||||||||
| AuthorizedOfficialMiddleName: | JANE | ||||||||
| AuthorizedOfficialTitleorPosition: | ASSISTANT | ||||||||
| AuthorizedOfficialTelephone: | 2313475511 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 01/21/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QR0401X | N | Ambulatory Health Care Facilities | Clinic/Center | Rehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF) | 261QP2300X | Y | Ambulatory Health Care Facilities | Clinic/Center | Primary Care |
ID Information
| ID | Type | State | Issuer | Description | SA0240037 | 05 | MI | MEDICAID |