Healthcare Provider Details

I. General information

NPI: 1174670459
Provider Name (Legal Business Name): COUNTY OF GRAND TRAVERSE
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/05/2007
Last Update Date: 09/12/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2600 LAFRANIER RD STE A
TRAVERSE CITY MI
49686-4765
US

IV. Provider business mailing address

2600 LAFRANIER RD STE A
TRAVERSE CITY MI
49686-4765
US

V. Phone/Fax

Practice location:
  • Phone: 231-995-6111
  • Fax: 231-995-6109
Mailing address:
  • Phone: 231-995-6111
  • Fax: 231-995-6109

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251K00000X
TaxonomyPublic Health or Welfare Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number4301028725
License Number StateMI

VIII. Authorized Official

Name: ERIN CARLSON
Title or Position: ACCOUNTANT
Credential:
Phone: 231-995-6103