Healthcare Provider Details

I. General information

NPI: 1407800931
Provider Name (Legal Business Name): CRISTO REY COMMUNITY CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/20/2006
Last Update Date: 10/02/2024
Certification Date: 10/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1717 N HIGH ST
LANSING MI
48906-4529
US

IV. Provider business mailing address

1717 N HIGH ST
LANSING MI
48906-4529
US

V. Phone/Fax

Practice location:
  • Phone: 517-371-1700
  • Fax: 517-371-4245
Mailing address:
  • Phone: 517-371-1700
  • Fax: 517-371-4245

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License NumberSL037010
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License NumberPC049423
License Number StateMI

VIII. Authorized Official

Name: DR. PETER H COOKE
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 517-371-1700