Healthcare Provider Details

I. General information

NPI: 1174724454
Provider Name (Legal Business Name): HEALTHY IMAGE SKIN AND BODY CLINIC PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2007
Last Update Date: 01/12/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2492 I-75
WEST BRANCH MI
48661
US

IV. Provider business mailing address

611 COURT ST PO BOX 428
WEST BRANCH MI
48661-0428
US

V. Phone/Fax

Practice location:
  • Phone: 989-345-3150
  • Fax:
Mailing address:
  • Phone: 989-516-4317
  • Fax: 989-345-5803

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: RICHARD MACAULEY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 989-345-3150