Healthcare Provider Details

I. General information

NPI: 1083034797
Provider Name (Legal Business Name): ALAN HURON BS LIBERAL STUDIES
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2014
Last Update Date: 04/21/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

349 JACKSON AVE BREAKTHROUGH BELIEVERS RECOVERY AND HEALING CENTER
MUSKEGON MI
49442-1114
US

IV. Provider business mailing address

PO BOX 204
SPARTA MI
49345-0204
US

V. Phone/Fax

Practice location:
  • Phone: 231-343-2753
  • Fax:
Mailing address:
  • Phone: 616-634-5435
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number410357
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code171W00000X
TaxonomyContractor
License Number410357
License Number StateMI
# 3
Primary TaxonomyN
Taxonomy Code172A00000X
TaxonomyDriver
License Number410357
License Number StateMI
# 4
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number410357
License Number StateMI
# 5
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number410357
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: