=====================================================
General NPI Number Information
=====================================================
NPI Number | 1881305712
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | GREAT LAKES HEALTH FOUNDATION INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/12/2022
-----------------------------------------------------
Last Update Date | 12/12/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4046 HESS AVE
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48601-4261
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-245-6633
-----------------------------------------------------
Fax | 989-355-0735
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 3061 CHRISTY WAY STE A
-----------------------------------------------------
City | SAGINAW
-----------------------------------------------------
State | MI
-----------------------------------------------------
Zip | 48603-2224
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 989-860-0088
-----------------------------------------------------
Fax | 989-355-0735
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. NAVEED MAHFOOZ
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 989-245-6633
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QF0400X
-----------------------------------------------------
Taxonomy Name | Federally Qualified Health Center (FQHC)
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------