Healthcare Provider Details

I. General information

NPI: 1154744597
Provider Name (Legal Business Name): HOLY FAMILY HEALTHCARE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/21/2014
Last Update Date: 07/19/2021
Certification Date: 07/19/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

301 N CENTER ST
HARTFORD MI
49057-1199
US

IV. Provider business mailing address

301 N CENTER ST
HARTFORD MI
49057-1199
US

V. Phone/Fax

Practice location:
  • Phone: 269-621-0011
  • Fax:
Mailing address:
  • Phone: 269-621-0011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801094934
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code176B00000X
TaxonomyMidwife
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number6801094934
License Number StateMI
# 6
Primary TaxonomyN
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code363AM0700X
TaxonomyMedical Physician Assistant
License Number5601002054
License Number StateMI
# 8
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5101011443
License Number StateMI

VIII. Authorized Official

Name: DR. DON D BOUCHARD
Title or Position: PRESIDENT
Credential: D.O.
Phone: 269-279-9332