| Organization Name: | CRYSTAL LAKE CLINIC, P.C. |
| NPI Number: | 1316177611 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | RICHARD C NIELSEN (PRESIDENT) |
| Mailing Address: | 2283 E M 113 Kingsley |
| State: | MI US |
| Postal Code: | 496499370 |
| Phone Number: | 2318829661 |
| Fax Number: | 2318829616 |
| NPI Enumeration Date: | 07/21/2009 |
| NPI Last Update Date: | 02/14/2011 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 261QR1300X |
| License Number: | |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | |
| Taxonomy Type: | Ambulatory Health Care Facilities |
| Taxonomy Classification: | Clinic/Center |
| Taxonomy Specialization: | Rural Health |
| Taxonomy Definition: | |