MEDICARE: INTERCARE COMMUNITY HEALTH NETWORK

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	261QF0400X	Federally Qualified Health Center (FQHC)

General Provider Information

NPI Number	:	1689845141
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTERCARE COMMUNITY HEALTH NETWORK

Provider Business Mailing Address
First Line	:	50 INDUSTRIAL PARK DRIVE
Second Line	:
City	:	BANGOR
State	:	MI
Zip	:	49013-1246
Country	:	US
Telephone Number	:	269-427-7937
Fax Number	:	269-427-5180

Provider Business Practice Location Address
First Line	:	960 AGARD AVE
Second Line	:
City	:	BENTON HARBOR
State	:	MI
Zip	:	49022-4051
Country	:	US
Telephone Number	:	269-927-5162
Fax Number	:	269-927-5319

Authorized Official
Title or Position	:	PRESIDENT/CEO
Name	:	VELMA HENDERSHOTT
Credential	:
Telephone Number	:	269-427-7937

Provider Enumeration Date	:	03/12/2008
Last Update Date	:	03/12/2008

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