Healthcare Provider Details

I. General information

NPI: 1861679664
Provider Name (Legal Business Name): ANOTHER PATH, PLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2008
Last Update Date: 05/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12100 S BENZONIA TRL
EMPIRE MI
49630
US

IV. Provider business mailing address

12100 S BENZONIA TRL
EMPIRE MI
49630-8503
US

V. Phone/Fax

Practice location:
  • Phone: 231-941-6670
  • Fax: 231-326-3026
Mailing address:
  • Phone: 231-941-6670
  • Fax: 231-326-3026

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number6801035572
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number4301038246
License Number StateMI

VIII. Authorized Official

Name: DR. DAVID R. HENDRICKS
Title or Position: PHYSICIAN
Credential: M.D.
Phone: 231-942-6670