Healthcare Provider Details

I. General information

NPI: 1114744802
Provider Name (Legal Business Name): CHARLES JACOB HUITEMA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/24/2024
Last Update Date: 09/24/2024
Certification Date: 09/18/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

829 W MAIN ST STE C3
GAYLORD MI
49735-1998
US

IV. Provider business mailing address

1181 NUS23
EAST TAWAS MI
48730
US

V. Phone/Fax

Practice location:
  • Phone: 989-732-6761
  • Fax:
Mailing address:
  • Phone: 989-260-2903
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: