Provider Demographics
NPI:1902851777
Name:CRYSTAL LAKE CLINIC, P.C.
Entity Type:Organization
Organization Name:CRYSTAL LAKE CLINIC, P.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:RICHARD
Authorized Official - Middle Name:C
Authorized Official - Last Name:NIELSEN
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:231-882-9661
Mailing Address - Street 1:6227 FRANKFORT HWY
Mailing Address - Street 2:
Mailing Address - City:BENZONIA
Mailing Address - State:MI
Mailing Address - Zip Code:49616-9654
Mailing Address - Country:US
Mailing Address - Phone:231-882-9661
Mailing Address - Fax:231-882-9616
Practice Address - Street 1:8225 LAKE ST
Practice Address - Street 2:
Practice Address - City:BEAR LAKE
Practice Address - State:MI
Practice Address - Zip Code:49614-9688
Practice Address - Country:US
Practice Address - Phone:231-864-3314
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-23
Last Update Date:2018-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI233891Medicare PIN
MI0N38430Medicare PIN