Healthcare Provider Details

I. General information

NPI: 1205902103
Provider Name (Legal Business Name): ELLA E. M. BROWN CHARITABLE CIRCLE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/24/2006
Last Update Date: 12/04/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

310 MICHIGAN AVE
MARSHALL MI
49068-1665
US

IV. Provider business mailing address

200 N MADISON ST
MARSHALL MI
49068-1143
US

V. Phone/Fax

Practice location:
  • Phone: 269-789-3921
  • Fax: 269-781-7117
Mailing address:
  • Phone: 269-789-3921
  • Fax: 269-781-7117

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QE0700X
TaxonomyEnd-Stage Renal Disease (ESRD) Treatment Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. COLLEEN M. KOPPENHAVER
Title or Position: CHIEF FINANCIAL OFFICER
Credential:
Phone: 269-789-3921