MEDICARE: ST. CLAIR COUNTY SHERIFF

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	251S00000X	Community/Behavioral Health Agency

General Provider Information

NPI Number	:	1053590935
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ST. CLAIR COUNTY SHERIFF

Provider Business Mailing Address
First Line	:	1170 MICHIGAN RD
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-4658
Country	:	US
Telephone Number	:	810-966-1625
Fax Number	:	810-966-4306

Provider Business Practice Location Address
First Line	:	1170 MICHIGAN RD
Second Line	:
City	:	PORT HURON
State	:	MI
Zip	:	48060-4658
Country	:	US
Telephone Number	:	810-966-1625
Fax Number	:	810-966-4306

Authorized Official
Title or Position	:	PROGRAM SERVICES COORDINATOR
Name	:	MS. KATHLEEN A BRANCH-GADD
Credential	:
Telephone Number	:	810-966-1625

Provider Enumeration Date	:	10/29/2007
Last Update Date	:	10/29/2007

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Directions to “ST. CLAIR COUNTY SHERIFF ” Practice Location

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