Healthcare Provider Details

I. General information

NPI: 1629252895
Provider Name (Legal Business Name): VAN BUREN CASS DISTRICT HEALTH DEPARTMENT
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/24/2007
Last Update Date: 12/24/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 WEST ARLINGTON BANGOR HEALTH CENTER
BANGOR MI
49013
US

IV. Provider business mailing address

57418 COUNTY ROAD 681
HARTFORD MI
49057-9421
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-6810
  • Fax:
Mailing address:
  • Phone: 269-621-3143
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6301006216
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6801063574
License Number StateMI

VIII. Authorized Official

Name: MR. JEFFERY L ELLIOTT
Title or Position: CHIEF HEALTH OFFICER
Credential: BBA
Phone: 269-621-3143