Provider Demographics
NPI:1922330851
Name:GLADWIN FAMILY CARE CENTER
Entity Type:Organization
Organization Name:GLADWIN FAMILY CARE CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:TAREK
Authorized Official - Middle Name:MUSTAPHA
Authorized Official - Last Name:EZZEDDINE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:989-426-9399
Mailing Address - Street 1:2137 W M 61
Mailing Address - Street 2:
Mailing Address - City:GLADWIN
Mailing Address - State:MI
Mailing Address - Zip Code:48624-8463
Mailing Address - Country:US
Mailing Address - Phone:989-426-9399
Mailing Address - Fax:989-246-2257
Practice Address - Street 1:2137 W M 61
Practice Address - Street 2:
Practice Address - City:GLADWIN
Practice Address - State:MI
Practice Address - Zip Code:48624-8463
Practice Address - Country:US
Practice Address - Phone:989-426-9399
Practice Address - Fax:989-246-2257
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-02-03
Last Update Date:2010-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4301080387174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty