Healthcare Provider Details

I. General information

NPI: 1568819464
Provider Name (Legal Business Name): LAKE GOGEBIC SENIOR CITIZENS CLUB, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2016
Last Update Date: 05/20/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

109 PINE STREET
BERGLAND MI
49910-0361
US

IV. Provider business mailing address

PO BOX 361
BERGLAND MI
49910-0361
US

V. Phone/Fax

Practice location:
  • Phone: 906-575-3461
  • Fax: 906-575-3462
Mailing address:
  • Phone: 906-575-3461
  • Fax: 906-575-3462

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: JOAN H HARRIS
Title or Position: DIRECTOR
Credential:
Phone: 906-575-3461