Provider Demographics
NPI:1417322884
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:ARLENE
Authorized Official - Middle Name:J
Authorized Official - Last Name:BRENNAN
Authorized Official - Suffix:
Authorized Official - Credentials:MHSA
Authorized Official - Phone:231-935-0351
Mailing Address - Street 1:3155 LOGAN VALLEY RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49684-4772
Mailing Address - Country:US
Mailing Address - Phone:231-935-0799
Mailing Address - Fax:231-935-0501
Practice Address - Street 1:105 HALL ST
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49684-2288
Practice Address - Country:US
Practice Address - Phone:231-935-4394
Practice Address - Fax:231-935-3696
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-12-10
Last Update Date:2016-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QF0400XAmbulatory Health Care FacilitiesClinic/CenterFederally Qualified Health Center (FQHC)
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI1669441457Medicaid
MI1265517494Medicaid