Provider Demographics
NPI:1073169835
Name:GREAT LAKES BAY HEALTH CENTERS
Entity Type:Organization
Organization Name:GREAT LAKES BAY HEALTH CENTERS
Other - Org Name:GREAT LAKES BAY HEALTH CENTERS BRIDGEPORT SPAULDING HIGH SCHOOL
Other - Org Type:Other Name
Authorized Official - Title/Position:PROVIDER ENROLLMENT
Authorized Official - Prefix:
Authorized Official - First Name:DAWN
Authorized Official - Middle Name:
Authorized Official - Last Name:CHRISTIAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:989-759-6464
Mailing Address - Street 1:501 LAPEER AVE
Mailing Address - Street 2:
Mailing Address - City:SAGINAW
Mailing Address - State:MI
Mailing Address - Zip Code:48607-1203
Mailing Address - Country:US
Mailing Address - Phone:989-759-6464
Mailing Address - Fax:989-399-8233
Practice Address - Street 1:4691 BEARCAT BLVD
Practice Address - Street 2:
Practice Address - City:BRIDGEPORT
Practice Address - State:MI
Practice Address - Zip Code:48722-9581
Practice Address - Country:US
Practice Address - Phone:989-777-0440
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-16
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)