Healthcare Provider Details

I. General information

NPI: 1841436128
Provider Name (Legal Business Name): BANGOR HEALTH CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/17/2008
Last Update Date: 05/07/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

803 WEST ARLINGTON STREET
BANGOR MI
49013-1108
US

IV. Provider business mailing address

PO BOX 249 801 HAZEN STREET, SUITE C.
PAW PAW MI
49079-0249
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-6810
  • Fax:
Mailing address:
  • Phone: 269-657-5574
  • Fax: 269-657-3474

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: MRS. DEBRA L.R. HESS
Title or Position: CHIEF EXECUTIVE OFFICER
Credential:
Phone: 269-567-5574