Provider Demographics
NPI:1336701119
Name:INTERCARE COMMUNITY HEALTH NETWORK
Entity Type:Organization
Organization Name:INTERCARE COMMUNITY HEALTH NETWORK
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 RD
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 1:7450 HOCHBERGER RD RM 15A
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:MI
Practice Address - Zip Code:49111-9762
Practice Address - Country:US
Practice Address - Phone:269-461-6947
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-07-02
Last Update Date:2019-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No101YS0200XBehavioral Health & Social Service ProvidersCounselorSchoolGroup - Multi-Specialty