Provider Demographics
NPI:1811186455
Name:BARAGA-HOUGHTON-KEWEENAW CHILD DEVELOPMENT BOARD
Entity Type:Organization
Organization Name:BARAGA-HOUGHTON-KEWEENAW CHILD DEVELOPMENT BOARD
Other - Org Name:BHK CHILD DEVELOPMENT BOARD, BHK, B-H-K, B-H-K CHILD DEVELOPMENT BOARD
Other - Org Type:Doing Business As
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:DALE
Authorized Official - Middle Name:H
Authorized Official - Last Name:PENNY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:906-482-3663
Mailing Address - Street 1:700 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:HOUGHTON
Mailing Address - State:MI
Mailing Address - Zip Code:49931
Mailing Address - Country:US
Mailing Address - Phone:906-482-3663
Mailing Address - Fax:906-482-7329
Practice Address - Street 1:700 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:HOUGHTON
Practice Address - State:MI
Practice Address - Zip Code:49931
Practice Address - Country:US
Practice Address - Phone:906-482-3663
Practice Address - Fax:906-482-7329
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-10-19
Last Update Date:2008-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
251K00000X
MITF073637251K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251K00000XAgenciesPublic Health or Welfare
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI3180978Medicaid