MEDICARE: CRYSTAL LAKE CLINIC P.C.

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	207Q00000X	Family Medicine Physician

General Provider Information

NPI Number	:	1386028769
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	CRYSTAL LAKE CLINIC P.C.

Provider Business Mailing Address
First Line	:	6227 FRANKFORT HWY
Second Line	:
City	:	BENZONIA
State	:	MI
Zip	:	49616-8632
Country	:	US
Telephone Number	:	231-882-9661
Fax Number	:	231-882-9616

Provider Business Practice Location Address
First Line	:	6170 US HIGHWAY 31 N
Second Line	:
City	:	WILLIAMSBURG
State	:	MI
Zip	:	49690-9306
Country	:	US
Telephone Number	:	231-715-3614
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	RICHARD C NIELSEN
Credential	:	M.D.
Telephone Number	:	231-882-9661

Provider Enumeration Date	:	07/15/2015
Last Update Date	:	07/15/2015

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