Provider Demographics
NPI:1669712907
Name:GRAND LAKE HEALTH CENTER LLC
Entity type:Organization
Organization Name:GRAND LAKE HEALTH CENTER LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR/OWNER
Authorized Official - Prefix:DR
Authorized Official - First Name:COREEN
Authorized Official - Middle Name:JEAN
Authorized Official - Last Name:WILLIAMS
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:989-354-0860
Mailing Address - Street 1:1691 M 32 W
Mailing Address - Street 2:SUITE 300
Mailing Address - City:ALPENA
Mailing Address - State:MI
Mailing Address - Zip Code:49707-8210
Mailing Address - Country:US
Mailing Address - Phone:989-354-0860
Mailing Address - Fax:989-354-0880
Practice Address - Street 1:1691 M 32 W
Practice Address - Street 2:SUITE 300
Practice Address - City:ALPENA
Practice Address - State:MI
Practice Address - Zip Code:49707-8210
Practice Address - Country:US
Practice Address - Phone:989-354-0860
Practice Address - Fax:989-354-0880
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-02-24
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704151039363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MI11905624OtherCAQH
MI0870556OtherBCBSM
MI500027624OtherRAILROAD MEDICARE
MI7000525321OtherPRIORITY HEALTH
MI4485877Medicaid
MI500027624OtherRAILROAD MEDICARE