Provider Demographics
NPI:1730466822
Name:SPECTRUM HEALTH KELSEY
Entity Type:Organization
Organization Name:SPECTRUM HEALTH KELSEY
Other - Org Name:LAKEVIEW YOUTH CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:VICE PRESIDENT FINANCE
Authorized Official - Prefix:
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:J
Authorized Official - Last Name:OEHRING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:616-225-6411
Mailing Address - Street 1:418 WASHINGTON ST
Mailing Address - Street 2:
Mailing Address - City:LAKEVIEW
Mailing Address - State:MI
Mailing Address - Zip Code:48850-9806
Mailing Address - Country:US
Mailing Address - Phone:989-352-6435
Mailing Address - Fax:989-352-8451
Practice Address - Street 1:420 S LINCOLN ST
Practice Address - Street 2:
Practice Address - City:LAKEVIEW
Practice Address - State:MI
Practice Address - Zip Code:48850-8500
Practice Address - Country:US
Practice Address - Phone:989-352-1800
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-11-03
Last Update Date:2011-11-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI0E96010Medicare PIN