MEDICARE: MISSAUKEE COUNTY COMMISSION ON AGING

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251E00000X	Home Health Agency

General Provider Information

NPI Number	:	1003325580
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MISSAUKEE COUNTY COMMISSION ON AGING

Provider Business Mailing Address
First Line	:	PO BOX 217
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-0217
Country	:	US
Telephone Number	:	231-839-7839
Fax Number	:	231-839-7630

Provider Business Practice Location Address
First Line	:	1980 S MOREY RD
Second Line	:
City	:	LAKE CITY
State	:	MI
Zip	:	49651-9380
Country	:	US
Telephone Number	:	231-839-7839
Fax Number	:	231-839-7630

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MRS. NATALIE ANNE DAVIS
Credential	:
Telephone Number	:	231-839-7839

Provider Enumeration Date	:	09/27/2017
Last Update Date	:	09/27/2017

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