=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144634775
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTER FOR FAMILY HEALTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/11/2014
-----------------------------------------------------
Last Update Date | 06/11/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 240 W CARLETON RD
-----------------------------------------------------
City | HILLSDALE
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49242-5034
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-748-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 505 N JACKSON ST
-----------------------------------------------------
City | JACKSON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49201-1266
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 517-748-5500
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MICHELLE MAYO
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 517-748-5500
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------