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General NPI Number Information
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NPI Number | 1518905264
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Entity Type | Organization
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Legal Business Name | GREAT LAKES FAMILY HEALTH CENTER PC
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Dates
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Enumeration Date | 06/03/2006
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Last Update Date | 10/03/2017
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Provider Practice Location Address
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Address Line | 3424 DAVENPORT AVE
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City | SAGINAW
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State | MI
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Zip | 48602-3365
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Country | US
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Telephone | 989-790-0100
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Fax | 989-790-0241
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Provider Business Mailing Address
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Address Line | 3424 DAVENPORT AVE
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City | SAGINAW
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State | MI
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Zip | 48602-3365
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Country | US
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Telephone | 989-790-0100
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Fax | 989-790-0241
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Authorized Official
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Title or Position | AUTHORIZED OFFICIAL
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Name | RODAMES D DEDICATORIA
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Credential |
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Telephone | 989-790-0100
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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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