Healthcare Provider Details

I. General information

NPI: 1497780654
Provider Name (Legal Business Name): TRI-CITY MEDICAL CLINIC PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/12/2006
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6633 RED ARROW HWY
COLOMA MI
49038-8717
US

IV. Provider business mailing address

6633 RED ARROW HWY
COLOMA MI
49038-8717
US

V. Phone/Fax

Practice location:
  • Phone: 269-468-7684
  • Fax: 269-468-7687
Mailing address:
  • Phone: 269-468-7684
  • Fax: 269-468-7687

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207RI0200X
TaxonomyInfectious Disease Physician
License Number4301068832
License Number StateMI

VIII. Authorized Official

Name: AURORA B MADANGUIT
Title or Position: OWNER
Credential: MD
Phone: 269-468-7684