Healthcare Provider Details

I. General information

NPI: 1992818835
Provider Name (Legal Business Name): INTERCARE COMMUNITY HEALTH NETWORK
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 01/03/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

308 CHARLES ST
BANGOR MI
49013
US

IV. Provider business mailing address

50 INDUSTRIAL PARK DR
BANGOR MI
49013
US

V. Phone/Fax

Practice location:
  • Phone: 269-427-7967
  • Fax: 269-427-9539
Mailing address:
  • Phone: 269-427-7937
  • Fax: 269-427-5180

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State

VIII. Authorized Official

Name: VELMA HENDERSHOTT
Title or Position: PRESIDENT CEO
Credential:
Phone: 269-427-7937