Provider Demographics
NPI:1114335767
Name:INTERCARE COMMUNITY HEATH NETWORK MEDICAL VAN
Entity Type:Organization
Organization Name:INTERCARE COMMUNITY HEATH NETWORK MEDICAL VAN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:VELMA
Authorized Official - Middle Name:
Authorized Official - Last Name:HENDERSHOTT
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:269-427-7937
Mailing Address - Street 1:50 INDUSTRIAL PARK DRIVE
Mailing Address - Street 2:
Mailing Address - City:BANGOR
Mailing Address - State:MI
Mailing Address - Zip Code:49013-1246
Mailing Address - Country:US
Mailing Address - Phone:269-427-7937
Mailing Address - Fax:269-427-5180
Practice Address - Street 1:308 CHARLES STREET
Practice Address - Street 2:
Practice Address - City:BANGOR
Practice Address - State:MI
Practice Address - Zip Code:49013-1246
Practice Address - Country:US
Practice Address - Phone:269-427-7937
Practice Address - Fax:269-427-5180
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-28
Last Update Date:2014-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)