=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336563832
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | UPPER GREAT LAKES FAMILY HEALTH CENTER
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/05/2014
-----------------------------------------------------
Last Update Date | 07/10/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 751 S 7TH STREET
-----------------------------------------------------
City | ONTONAGON
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49953-1450
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-884-4120
-----------------------------------------------------
Fax | 906-372-3230
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 301 EXPLORER ST
-----------------------------------------------------
City | GWINN
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49841-2813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 906-884-4120
-----------------------------------------------------
Fax | 906-372-3230
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | TREVOR HODGES
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 906-483-1846
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------