=====================================================
General NPI Number Information
=====================================================
NPI Number | 1306866215
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CENTRAL MICHIGAN FAMILY PRACTICE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/20/2006
-----------------------------------------------------
Last Update Date | 12/10/2010
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 522 EAST MAIN STREET
-----------------------------------------------------
City | FARWELL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-588-6153
-----------------------------------------------------
Fax | 989-588-6194
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 522 EAST MAIN STREET
-----------------------------------------------------
City | FARWELL
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48622
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-588-6153
-----------------------------------------------------
Fax | 989-588-6194
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | DR. BROCK W HORSLEY
-----------------------------------------------------
Credential | D.O
-----------------------------------------------------
Telephone | 989-588-6153
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 207Q00000X
-----------------------------------------------------
Taxonomy Name | Family Medicine Physician
-----------------------------------------------------
License Number | 5101014871
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------