Provider Demographics
NPI:1114958691
Name:EAST JORDAN FAMILY HEALTH CENTER
Entity Type:Organization
Organization Name:EAST JORDAN FAMILY HEALTH CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DANIEL
Authorized Official - Middle Name:
Authorized Official - Last Name:MCKINNON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-536-2206
Mailing Address - Street 1:601 BRIDGE ST
Mailing Address - Street 2:
Mailing Address - City:EAST JORDAN
Mailing Address - State:MI
Mailing Address - Zip Code:49727-9383
Mailing Address - Country:US
Mailing Address - Phone:231-536-2206
Mailing Address - Fax:231-536-9864
Practice Address - Street 1:601 BRIDGE ST
Practice Address - Street 2:
Practice Address - City:EAST JORDAN
Practice Address - State:MI
Practice Address - Zip Code:49727-9383
Practice Address - Country:US
Practice Address - Phone:231-536-2206
Practice Address - Fax:231-536-9864
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-05
Last Update Date:2013-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0A56344Medicare PIN
MI231803Medicare Oscar/Certification