Provider Demographics
NPI:1174843353
Name:INTERLOCHEN CENTER FOR THE ARTS
Entity Type:Organization
Organization Name:INTERLOCHEN CENTER FOR THE ARTS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF HEALTH AND WELLNESS
Authorized Official - Prefix:MS
Authorized Official - First Name:NANCY
Authorized Official - Middle Name:L
Authorized Official - Last Name:GIFFELS
Authorized Official - Suffix:
Authorized Official - Credentials:NP
Authorized Official - Phone:231-276-7220
Mailing Address - Street 1:PO BOX 199
Mailing Address - Street 2:SUITE F
Mailing Address - City:INTERLOCHEN
Mailing Address - State:MI
Mailing Address - Zip Code:49643-0199
Mailing Address - Country:US
Mailing Address - Phone:231-276-7220
Mailing Address - Fax:231-276-7881
Practice Address - Street 1:9900 DIAMOND PARK ROAD
Practice Address - Street 2:HEALTH SERVICES
Practice Address - City:INTERLOCHEN
Practice Address - State:MI
Practice Address - Zip Code:49643-0199
Practice Address - Country:US
Practice Address - Phone:231-276-7220
Practice Address - Fax:231-276-7881
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-06-10
Last Update Date:2010-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704114336363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1922003367Medicaid
MI264027354OtherCHAMPUS
MINC114336OtherBCBS
MINC114336OtherBCBS