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General NPI Number Information
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NPI Number | 1679855498
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Entity Type | Organization
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Legal Business Name | BAYSIDE LODGE
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Dates
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Enumeration Date | 09/19/2011
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Last Update Date | 12/03/2013
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Provider Practice Location Address
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Address Line | 2700 W GENESEE AVE
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City | SAGINAW
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State | MI
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Zip | 48602-3723
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Country | US
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Telephone | 989-799-1266
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Fax | 989-799-1548
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Provider Business Mailing Address
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Address Line | 1450 S LAPEER RD
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City | OXFORD
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State | MI
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Zip | 48371-6108
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Country | US
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Telephone | 248-969-9932
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Fax | 248-969-3006
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Authorized Official
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Title or Position | DIRECTOR
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Name | JACQULINE KISS WILSON
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Credential |
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Telephone | 248-969-9932
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251S00000X
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Taxonomy Name | Community/Behavioral Health Agency
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License Number |
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License Number State |
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