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General NPI Number Information
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NPI Number | 1164945978
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Entity Type | Organization
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Legal Business Name | CRYSTAL LAKE CLINIC P.C.
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Dates
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Enumeration Date | 07/24/2017
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Last Update Date | 07/24/2017
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Provider Practice Location Address
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Address Line | 650 S WEST BAY SHORE DR
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City | SUTTONS BAY
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State | MI
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Zip | 49682-9587
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Country | US
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Telephone | 231-882-9661
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Fax |
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Provider Business Mailing Address
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Address Line | 6227 FRANKFORT HWY
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City | BENZONIA
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State | MI
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Zip | 49616-8632
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Country | US
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Telephone | 231-882-9661
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Fax |
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Authorized Official
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Title or Position | PRESIDENT
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Name | RICHARD C NIELSEN
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Credential | MD
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Telephone | 231-882-9661
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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