Healthcare Provider Details

I. General information

NPI: 1942446927
Provider Name (Legal Business Name): COMMUNITY ACTION AGENCY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/23/2008
Last Update Date: 09/20/2024
Certification Date: 09/20/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 W SOUTH ST
ADRIAN MI
49221-3825
US

IV. Provider business mailing address

400 W SOUTH ST
ADRIAN MI
49221-3825
US

V. Phone/Fax

Practice location:
  • Phone: 517-263-7861
  • Fax: 517-263-6531
Mailing address:
  • Phone: 517-263-7861
  • Fax: 517-263-6531

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133NN1002X
TaxonomyNutrition Education Nutritionist
License Number4703062118
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code305S00000X
TaxonomyPoint of Service
License Number4703062118
License Number StateMI

VIII. Authorized Official

Name: TOBY BERRY
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 517-539-8311