Healthcare Provider Details

I. General information

NPI: 1477985240
Provider Name (Legal Business Name): HEALTHCARE COORDINATES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/05/2013
Last Update Date: 08/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11461 FREDMAR DR
INTERLOCHEN MI
49643-9523
US

IV. Provider business mailing address

PO BOX 466
TRAVERSE CITY MI
49685-0466
US

V. Phone/Fax

Practice location:
  • Phone: 231-590-8624
  • Fax:
Mailing address:
  • Phone: 231-590-8624
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number4704107861
License Number StateMI

VIII. Authorized Official

Name: MARY PAT RANDALL
Title or Position: CEO
Credential: RN
Phone: 231-590-8624