Organization Name: | CRYSTAL LAKE CLINIC, P.C. |
NPI Number: | 1902851777 |
Entity Type Code: | Organizational (2) |
Authorized Official Name: | RICHARD C NIELSEN (PRESIDENT) |
Mailing Address: | 8225 Lake St Bear Lake |
State: | MI US |
Postal Code: | 496149688 |
Phone Number: | 2318643314 |
Fax Number: | |
NPI Enumeration Date: | 05/23/2006 |
NPI Last Update Date: | 01/18/2010 |
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: |