MEDICARE: CLINTON EVERETT MIRELES BA, CHW

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	172V00000X	Community Health Worker		MI

General Provider Information

NPI Number	:	1013863257
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CLINTON EVERETT MIRELES BA, CHW

Provider Business Mailing Address
First Line	:	5303 S CEDAR ST STE 201
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48911-3800
Country	:	US
Telephone Number	:	517-887-4311
Fax Number	:

Provider Business Practice Location Address
First Line	:	5303 S CEDAR ST STE 201
Second Line	:
City	:	LANSING
State	:	MI
Zip	:	48911-3800
Country	:	US
Telephone Number	:	517-887-4311
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/09/2026
Last Update Date	:	03/09/2026

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