Provider Demographics
NPI:1407309685
Name:TRAVERSE HEALTH CLINIC AND COALITION
Entity Type:Organization
Organization Name:TRAVERSE HEALTH CLINIC AND COALITION
Other - Org Name:TRAVERSE HEALTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:CASEY
Authorized Official - Middle Name:
Authorized Official - Last Name:KANDOW
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:231-935-0799
Mailing Address - Street 1:1719 S GARFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-4337
Mailing Address - Country:US
Mailing Address - Phone:231-935-0799
Mailing Address - Fax:231-935-0962
Practice Address - Street 1:1719 S GARFIELD AVE
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-4337
Practice Address - Country:US
Practice Address - Phone:231-935-0799
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-07-25
Last Update Date:2023-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
No343900000XTransportation ServicesNon-emergency Medical Transport (VAN)