Healthcare Provider Details

I. General information

NPI: 1760888002
Provider Name (Legal Business Name): ALCONA CITIZENS FOR HEALTH, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2014
Last Update Date: 11/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4999 HERRON RD
HERRON MI
49744-9600
US

IV. Provider business mailing address

4999 HERRON RD
HERRON MI
49744-9600
US

V. Phone/Fax

Practice location:
  • Phone: 989-358-5700
  • Fax:
Mailing address:
  • Phone: 989-358-5700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number6801088331
License Number StateMI

VIII. Authorized Official

Name: ELIZABETH GODDARD
Title or Position: INS CREDENTIALING
Credential:
Phone: 989-736-9815