Healthcare Provider Details

I. General information

NPI: 1790894988
Provider Name (Legal Business Name): WEST BRANCH PULMONARY CLINIC PC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/30/2006
Last Update Date: 01/05/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

780 N GAVORD RD
STERLING MI
48659-9703
US

IV. Provider business mailing address

780 N GAVORD RD
STERLING MI
48659-9703
US

V. Phone/Fax

Practice location:
  • Phone: 989-654-2168
  • Fax: 989-654-2825
Mailing address:
  • Phone: 989-654-2168
  • Fax: 989-654-2825

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberTM0009037
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code261QS1200X
TaxonomySleep Disorder Diagnostic Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: MS. VICKI LYNN HERRICK
Title or Position: INSURANCE BILLER
Credential:
Phone: 810-564-9270