=====================================================
General NPI Number Information
=====================================================
NPI Number | 1407677990
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | HARBORS NORTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/18/2024
-----------------------------------------------------
Last Update Date | 12/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3890 CHARLEVOIX RD STE 210
-----------------------------------------------------
City | PETOSKEY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49770-8420
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-445-1898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1 ALTAIR DR
-----------------------------------------------------
City | BOYNE CITY
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 49712-9618
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 231-445-1898
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | MR. RYAN SCHELLDORF
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 231-445-1898
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2084P0800X
-----------------------------------------------------
Taxonomy Name | Psychiatry Physician
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------