Healthcare Provider Details

I. General information

NPI: 1275783342
Provider Name (Legal Business Name): KEWEENAW HOLISTIC FAMILY MEDICINE, PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/25/2008
Last Update Date: 07/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

56611 CALUMET AVE
CALUMET MI
49913-1603
US

IV. Provider business mailing address

56611 CALUMET AVE
CALUMET MI
49913-1603
US

V. Phone/Fax

Practice location:
  • Phone: 906-337-1844
  • Fax:
Mailing address:
  • Phone: 906-337-1844
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number4704208143
License Number StateMI

VIII. Authorized Official

Name: JILL E. KALCICH
Title or Position: PRESIDENT
Credential: M.D.
Phone: 906-337-1844