Provider Demographics
NPI:1851707517
Name:NORTHERN LIGHT, INC
Entity Type:Organization
Organization Name:NORTHERN LIGHT, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GARY
Authorized Official - Middle Name:W
Authorized Official - Last Name:DAVIS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:810-955-3130
Mailing Address - Street 1:PO BOX 185
Mailing Address - Street 2:
Mailing Address - City:RAPID CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49676-0185
Mailing Address - Country:US
Mailing Address - Phone:810-955-3130
Mailing Address - Fax:231-587-5267
Practice Address - Street 1:9712 MAPLE ST
Practice Address - Street 2:
Practice Address - City:RAPID CITY
Practice Address - State:MI
Practice Address - Zip Code:49676-9213
Practice Address - Country:US
Practice Address - Phone:810-955-3130
Practice Address - Fax:231-587-5267
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-07-02
Last Update Date:2014-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health