Healthcare Provider Details

I. General information

NPI: 1215055306
Provider Name (Legal Business Name): GREAT LAKES BAY HEALTH CENTERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/27/2007
Last Update Date: 09/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6297 DIXIE HIGHWAY
BRIDGEPORT MI
48722-9635
US

IV. Provider business mailing address

501 LAPEER
SAGINAW MI
48607-1208
US

V. Phone/Fax

Practice location:
  • Phone: 989-759-6460
  • Fax: 989-759-6465
Mailing address:
  • Phone: 989-759-6464
  • Fax: 989-399-8233

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: LISA GALONSKA
Title or Position: VICE PRESIDENT
Credential:
Phone: 989-759-6464