Healthcare Provider Details

I. General information

NPI: 1831866821
Provider Name (Legal Business Name): TRAVERSE HEALTH CLINIC AND COALITION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 07/12/2023
Certification Date: 07/12/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1719 S GARFIELD AVE
TRAVERSE CITY MI
49686-4337
US

IV. Provider business mailing address

1719 S GARFIELD AVE
TRAVERSE CITY MI
49686-4337
US

V. Phone/Fax

Practice location:
  • Phone: 231-935-0799
  • Fax: 231-935-0962
Mailing address:
  • Phone: 231-935-0799
  • Fax: 231-935-0962

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QF0400X
TaxonomyFederally Qualified Health Center (FQHC)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number
License Number State

VIII. Authorized Official

Name: CASEY KANDOW
Title or Position: CEO
Credential:
Phone: 231-935-0799