Healthcare Provider Details

I. General information

NPI: 1235208182
Provider Name (Legal Business Name): STATE OF MICHIGAN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/07/2006
Last Update Date: 07/23/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1400 W PICKARD ST
MT PLEASANT MI
48858-1364
US

IV. Provider business mailing address

P.O. BOX 30437
LANSING MI
48909-7937
US

V. Phone/Fax

Practice location:
  • Phone: 989-773-7921
  • Fax:
Mailing address:
  • Phone: 517-335-8245
  • Fax: 517-335-6995

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code3336L0003X
TaxonomyLong Term Care Pharmacy
License Number5301001112
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code282E00000X
TaxonomyLong Term Care Hospital
License Number5301001112
License Number StateMI

VIII. Authorized Official

Name: CYNTHIA KELLY
Title or Position: DIRECTOR OF HOSPITAL - CNETERS
Credential:
Phone: 517-335-0263