Basic Information
| Provider Information | |||||||||
| NPI: | 1801119466 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | ALLEGAN COUNTY COMMUNITY MENTAL HEALTH | ||||||||
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| OtherOrganizationName: | ALLEGAN COUNTY CMH | ||||||||
| OtherOrganizationType: | 5 | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3283 122ND AVE | ||||||||
| Address2: | PO DRAWER 130 | ||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490109511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696736617 | ||||||||
| FaxNumber: | 2696864601 | ||||||||
| Practice Location | |||||||||
| Address1: | 3283 122ND AVE | ||||||||
| Address2: | PO DRAWER 130 | ||||||||
| City: | ALLEGAN | ||||||||
| State: | MI | ||||||||
| PostalCode: | 490109511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2696736617 | ||||||||
| FaxNumber: | 2696864601 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/10/2010 | ||||||||
| LastUpdateDate: | 03/18/2010 | ||||||||
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| AuthorizedOfficialLastName: | ST. JOHN | ||||||||
| AuthorizedOfficialFirstName: | PEGGY | ||||||||
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| AuthorizedOfficialTitleorPosition: | FINANCE DIRECTOR | ||||||||
| AuthorizedOfficialTelephone: | 2696736617 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 261QM0801X | Y | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
ID Information
| ID | Type | State | Issuer | Description | 774352861 | 05 | MI | MEDICAID |