=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396867081
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ARBOR CIRCLE CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/04/2007
-----------------------------------------------------
Last Update Date | 08/22/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3736 GROVELAND AVE SW
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49519-3731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-249-0633
-----------------------------------------------------
Fax | 616-451-0020
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3736 GROVELAND AVE SW
-----------------------------------------------------
City | WYOMING
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49519-3731
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 616-249-0633
-----------------------------------------------------
Fax | 616-451-0020
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PROGRAM MANAGER
-----------------------------------------------------
Name | MR. ROGER HENRY WIEGERS
-----------------------------------------------------
Credential | LMSW
-----------------------------------------------------
Telephone | 616-459-7215
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 302R00000X
-----------------------------------------------------
Taxonomy Name | Health Maintenance Organization
-----------------------------------------------------
License Number | 6801017474
-----------------------------------------------------
License Number State | MI
-----------------------------------------------------