Provider Demographics
NPI:1942384409
Name:USCG AIRSTA TRAVERSE CITY CLINIC
Entity Type:Organization
Organization Name:USCG AIRSTA TRAVERSE CITY CLINIC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CHIEF HEALTH SERVICES
Authorized Official - Prefix:DR
Authorized Official - First Name:KELLY
Authorized Official - Middle Name:LOUISE
Authorized Official - Last Name:BUTTRICK
Authorized Official - Suffix:
Authorized Official - Credentials:DDS
Authorized Official - Phone:231-922-8282
Mailing Address - Street 1:1175 AIRPORT ACCESS RD
Mailing Address - Street 2:
Mailing Address - City:TRAVERSE CITY
Mailing Address - State:MI
Mailing Address - Zip Code:49686-3513
Mailing Address - Country:US
Mailing Address - Phone:231-922-8282
Mailing Address - Fax:231-922-8292
Practice Address - Street 1:1175 AIRPORT ACCESS RD
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-3513
Practice Address - Country:US
Practice Address - Phone:231-922-8282
Practice Address - Fax:231-922-8292
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-10-24
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth Service