Healthcare Provider Details

I. General information

NPI: 1952628893
Provider Name (Legal Business Name): AUSABLE VALLEY CMH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/03/2010
Last Update Date: 05/03/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1199 HARRIS AVE
TAWAS CITY MI
48763-9681
US

IV. Provider business mailing address

PO BOX 310
TAWAS CITY MI
48764-0310
US

V. Phone/Fax

Practice location:
  • Phone: 989-362-8636
  • Fax:
Mailing address:
  • Phone: 989-362-8636
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: BONNIE LIXEY
Title or Position: REIMBURSEMENTS SUPERVISOR
Credential: RN
Phone: 989-362-8636