Healthcare Provider Details

I. General information

NPI: 1851707517
Provider Name (Legal Business Name): NORTHERN LIGHT, INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9712 MAPLE ST
RAPID CITY MI
49676-9213
US

IV. Provider business mailing address

PO BOX 185
RAPID CITY MI
49676-0185
US

V. Phone/Fax

Practice location:
  • Phone: 810-955-3130
  • Fax: 231-587-5267
Mailing address:
  • Phone: 810-955-3130
  • Fax: 231-587-5267

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number StateMI

VIII. Authorized Official

Name: GARY W DAVIS
Title or Position: PRESIDENT
Credential:
Phone: 810-955-3130