=====================================================
General NPI Number Information
=====================================================
NPI Number | 1083127880
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | THE ARC SHIAWASSEE COUNTY INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/15/2017
-----------------------------------------------------
Last Update Date | 11/15/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1905 WEST M-21
-----------------------------------------------------
City | OWOSSO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-723-7377
-----------------------------------------------------
Fax | 989-725-6113
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 63 1905 WEST M-21
-----------------------------------------------------
City | OWOSSO
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48867
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-723-7377
-----------------------------------------------------
Fax | 989-725-6113
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | EXECUTIVE DIRECTOR
-----------------------------------------------------
Name | LYNN KOVALIK GRUBB
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 989-723-7377
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 385HR2050X
-----------------------------------------------------
Taxonomy Name | Respite Care Camp
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 385H00000X
-----------------------------------------------------
Taxonomy Name | Respite Care
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------