Provider Demographics
NPI:1225059587
Name:CHEBOYGAN LIFE SUPPORT SYSTEMS INC
Entity Type:Organization
Organization Name:CHEBOYGAN LIFE SUPPORT SYSTEMS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR OF CLSS
Authorized Official - Prefix:MR
Authorized Official - First Name:DALLAS
Authorized Official - Middle Name:LEE
Authorized Official - Last Name:HYDE
Authorized Official - Suffix:I
Authorized Official - Credentials:PARAMEDIC
Authorized Official - Phone:231-627-9348
Mailing Address - Street 1:536 RIGGS DR
Mailing Address - Street 2:P.O. BOX 105
Mailing Address - City:CHEBOYGAN
Mailing Address - State:MI
Mailing Address - Zip Code:49721-1063
Mailing Address - Country:US
Mailing Address - Phone:231-627-9348
Mailing Address - Fax:231-627-1658
Practice Address - Street 1:536 RIGGS DR
Practice Address - Street 2:
Practice Address - City:CHEBOYGAN
Practice Address - State:MI
Practice Address - Zip Code:49721-1063
Practice Address - Country:US
Practice Address - Phone:231-627-9348
Practice Address - Fax:231-627-1658
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-22
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI1610033416L0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3416L0300XTransportation ServicesAmbulanceLand Transport
Provider Identifiers
StateIdentifier IDID TypeIssuer
P42574OtherBLUE CARE NETWORK
MI1486558Medicaid
MI590A60009OtherBLUE CROSS BLUE SHEILD
P42574OtherBLUE CARE NETWORK