Basic Information
| Provider Information | |||||||||
| NPI: | 1760452122 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | IONIA COUNTY COMMUNITY MENTAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 375 APPLE TREE DR | ||||||||
| Address2: | |||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488467506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165271790 | ||||||||
| FaxNumber: | 6165270538 | ||||||||
| Practice Location | |||||||||
| Address1: | 375 APPLE TREE DR | ||||||||
| Address2: | |||||||||
| City: | IONIA | ||||||||
| State: | MI | ||||||||
| PostalCode: | 488467506 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6165271790 | ||||||||
| FaxNumber: | 6165270538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/26/2006 | ||||||||
| LastUpdateDate: | 05/27/2009 | ||||||||
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| AuthorizedOfficialLastName: | BECKMANN | ||||||||
| AuthorizedOfficialFirstName: | DANIEL | ||||||||
| AuthorizedOfficialMiddleName: | A | ||||||||
| AuthorizedOfficialTitleorPosition: | CHIEF FINANCIAL OFFICER | ||||||||
| AuthorizedOfficialTelephone: | 6165271790 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| AuthorizedOfficialCredential: | BS | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 251K00000X | MI | Y | Agencies | Public Health or Welfare |
ID Information
| ID | Type | State | Issuer | Description | 7509105840 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 211715928 | 05 | MI | MEDICAID | 7509104830 | 01 | MI | BLUE CROSS BLUE SHIELD | OTHER | 774350393 | 05 | MI | MEDICAID |