Healthcare Provider Details

I. General information

NPI: 1841536265
Provider Name (Legal Business Name): NLCMH
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/13/2012
Last Update Date: 12/13/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 HALL ST
TRAVERSE CITY MI
49684-2288
US

IV. Provider business mailing address

105 HALL ST
TRAVERSE CITY MI
49684-2288
US

V. Phone/Fax

Practice location:
  • Phone: 231-922-4850
  • Fax:
Mailing address:
  • Phone: 231-922-4850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number6802065562
License Number StateMI

VIII. Authorized Official

Name: MR. BRIAN DAVID BEE
Title or Position: CASE MANAGER
Credential: LBSW
Phone: 231-933-4944