Provider Demographics
NPI:1386028769
Name:CRYSTAL LAKE CLINIC P.C.
Entity Type:Organization
Organization Name:CRYSTAL LAKE CLINIC P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-882-9661
Mailing Address - Street 1:6227 FRANKFORT HWY
Mailing Address - Street 2:
Mailing Address - City:BENZONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49616-8632
Mailing Address - Country:US
Mailing Address - Phone:231-882-9661
Mailing Address - Fax:231-882-9616
Practice Address - Street 1:6170 US HIGHWAY 31 N
Practice Address - Street 2:
Practice Address - City:WILLIAMSBURG
Practice Address - State:MI
Practice Address - Zip Code:49690-9306
Practice Address - Country:US
Practice Address - Phone:231-715-3614
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-07-15
Last Update Date:2015-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0N38430Medicare PIN