Organization Name: | COVERED BRIDGE HEALTHCARE OF ST. JOSEPH COUNTY INC |
NPI Number: | 1063876910 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | LYNN DOBBERTEEN (EXECUTIVE DIRECTOR) |
Mailing Address: | 635 E Main St Centreville |
State: | MI US |
Postal Code: | 490329699 |
Phone Number: | 2696257855 |
Fax Number: | |
NPI Enumeration Date: | 04/07/2016 |
NPI Last Update Date: | 04/29/2016 |
Replacement NPI: | 0 |
NPI Deactivation Date: | |
NPI Reactivation Date: |
Taxonomy Information: | |
Healthcare Provider Taxonomy: | 261QF0400X |
License Number: | |
Healthcare Provider Taxonomy: (Secondary) | Y |
State: | |
Taxonomy Type: | Ambulatory Health Care Facilities |
Taxonomy Classification: | Clinic/Center |
Taxonomy Specialization: | Federally Qualified Health Center (FQHC) |
Taxonomy Definition: |