Healthcare Provider Details

I. General information

NPI: 1902851777
Provider Name (Legal Business Name): CRYSTAL LAKE CLINIC, P.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/23/2006
Last Update Date: 11/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8225 LAKE ST
BEAR LAKE MI
49614-9688
US

IV. Provider business mailing address

6227 FRANKFORT HWY
BENZONIA MI
49616-9654
US

V. Phone/Fax

Practice location:
  • Phone: 231-864-3314
  • Fax:
Mailing address:
  • Phone: 231-882-9661
  • Fax: 231-882-9616

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: RICHARD C NIELSEN
Title or Position: PRESIDENT
Credential: M.D.
Phone: 231-882-9661